Reunion of Digits.—An interesting phenomenon noticed in relation to severed digits is their wonderful capacity for reunion. Restitution of a severed part, particularly if one of considerable function, naturally excited the interest of the older writers. Locher has cited an instance of avulsion of the finger with restitution of the avulsed portion; and Brulet, Van Esh, Farmer, Ponteau, Regnault, and Rosenberg cite instances of reunion of a digit after amputation or severance. Eve's "Remarkable Cases in Surgery" contains many instances of reunion of both fingers and thumbs, and in more recent years several other similar cases have been reported. At the Emergency Hospital in Washington, D.C., there was a boy brought in who had completely severed one of his digits by a sharp bread-cutter. The amputated finger was wrapped up in a piece of brown paper, and, being apparently healthy and the wound absolutely clean, it was fixed in the normal position on the stump, and covered by a bichlorid dressing. In a short time complete function was restored. In this instance no joint was involved, the amputation being in the middle of the 2d phalanx. Staton has described a case in which the hand was severed from the arm by an accidental blow from an axe. The wound extended from the styloid process directly across to the trapezium, dividing all the muscles and blood-vessels, cutting through bones. A small portion of the skin below the articulation, with the ulna, remained intact. After an unavoidable delay of an hour, Staton proceeded to replace the hand with silver sutures, adhesive plaster, and splints. On the third day pulsation was plainly felt in the hand, and on the fourteenth day the sutures were removed. After some time the patient was able to extend the fingers of the wounded member, and finally to grasp with all her wonted strength.
The reproduction or accidental production of nails after the original part has been torn away by violence or destroyed by disease, is quite interesting. Sometimes when the whole last phalanx has been removed, the nail regrows at the tip of the remaining stump. Tulpius seems to have met with this remarkable condition. Marechal de Rougeres, Voigtel, and Ormancey have related instances of similar growths on the 2d phalanx after the loss of the 1st. For several months a woman had suffered from an ulcer of the middle finger of the right hand, in consequence of a whitlow; there was loss of the 3d phalanx, and the whole of the articular surface and part of the compact bony structure of the 2d. On examining the sore, Ormangey saw a bony sequestrum which appeared to keep it open. He extracted this, and, until cicatrization was complete, he dressed the stump with saturnine cerate. Some months afterward Ormangey saw with astonishment that the nail had been reproduced; instead of following the ordinary direction, however, it lay directly over the face of the stump, growing from the back toward the palmer aspect of the stump digit, as if to cover and protect the stump. Blandin has observed a case of the same description. A third occurred at the Hopital de la Charite, in a woman, who, in consequence of a whitlow, had lost the whole of the 3d phalanx of one of the forefingers. The soft and fleshy cushion which here covered the 2d phalanx was terminated by a small, blackish nail, like a grain of spur rye. It is probable that in these cases the soft parts of the 3d phalanx, and especially the ungual matrix, had not been wholly destroyed. In his lectures Chevalier speaks of analogous cases.
In some instances avulsion of a finger is effected in a peculiar manner. In 1886 Anche reported to his confreres in Bordeaux a rare accident of this nature that occurred to a carpenter. The man's finger was caught between a rope and the block of a pulley. By a sudden and violent movement on his part he disengaged the hand but left the 3d finger attached to the pulley. At first examination the wound looked like that of an ordinary amputation by the usual oval incision; from the center of the wound the proximal fragment of the 1st phalanx projected. Polaillon has collected 42 similar instances, in none of which, however, was the severance complete.
It occasionally happens that in avulsion of the finger an entire tendon is stripped up and torn off with the detached member. Vogel describes an instance of this nature, in which the long flexor of the thumb was torn off with that digit. In the Surgical Museum at Edinburgh there is preserved a thumb and part of the flexor longus pollicis attached, which were avulsed simultaneously. Nunnely has seen the little finger together with the tendon and body of the longer flexor muscle avulsed by machinery. Stone details the description of the case of a boy named Lowry, whose left thumb was caught between rapidly twisting strands of a rope, and the last phalanx, the neighboring soft parts, and also the entire tendon of the flexor longus pollicis were instantly torn away. There was included even the tendinous portion of that small slip of muscle taking its origin from the anterior aspect of the head and upper portion of the ulna, and which is so delicate and insignificant as to be generally overlooked by anatomists. There was great pain along the course of the tract of abstraction of the tendon.
Pinkerton describes a carter of thirty-one who was bitten on the thumb by a donkey. The man pulled violently in one direction, and the donkey, who had seized the thumb firmly with his teeth, pulled forcibly in the other direction until the tissues gave way and the man ran off, leaving his thumb in the donkey's mouth. The animal at once dropped the thumb, and it was picked up by a companion who accompanied the man to the hospital. On examination the detached portion was found to include the terminal phalanx of the thumb, together with the tendon of the flexor longus pollicis measuring ten inches, about half of which length had a fringe of muscular tissue hanging from the free borders, indicating the extent and the penniform arrangement of the fibers attached to it. Meyer cites a case in which the index finger was torn off and the flexor muscle twisted from its origin. The authors know of an unreported case in which a man running in the street touched his hand to a hitching block he was passing; a ring on one of his fingers caught in the hook of the block, and tore off the finger with the attached tendon and muscle. There is a similar instance of a Scotch gentleman who slipped, and, to prevent falling, he put out his hand to catch the railing. A ring on one of his fingers became entangled in the railing and the force of the fall tore off the soft parts of the finger together with the ring.
The older writers mentioned as a curious fact that avulsion of the arm, unaccompanied by hemorrhage, had been noticed. Belchier, Carmichael, and Clough report instances of this nature, and, in the latter case, the progress of healing was unaccompanied by any uncomfortable symptoms. In the last century Hunezoysky observed complete avulsion of the arm by a cannon-ball, without the slightest hemorrhage. The Ephemerides contains an account of the avulsion of the hand without any bleeding, and Woolcomb has observed a huge wound of the arm from which hemorrhage was similarly absent. Later observations have shown that in this accident absence of hemorrhage is the rule and not the exception. The wound is generally lacerated and contused and the mouths of the vessels do not gape, but are twisted and crushed. The skin usually separates at the highest point and the muscles protrude, appearing to be tightly embraced and almost strangulated by the skin, and also by the tendons, vessels, and nerves which, crushed and twisted with the fragments of bone, form a conical stump. Cheselden reports the history of a case, which has since become classic, that he observed in St. Thomas' Hospital in London, in 1837. A miller had carelessly thrown a slip-knot of rope about his wrist, which became caught in a revolving cog, drawing him from the ground and violently throwing his body against a beam. The force exerted by the cog drawing on the rope was sufficient to avulse his whole arm and shoulder-blade. There was comparatively little hemorrhage and the man was insensible to pain; being so dazed and surprised he really was unconscious of the nature of his injury until he saw his arm in the wheel.
According to Billroth the avulsion of an arm is usually followed by fatal shock. Fischer, however, relates the case of a lion-tamer whose whole left arm was torn from the shoulder by a lion; the loss of blood being very slight and the patient so little affected by shock that he was able to walk to the hospital.
Mussey describes a boy of sixteen who had his left arm and shoulder-blade completely torn from his body by machinery. The patient became so involved in the bands that his body was securely fastened to a drum, while his legs hung dangling. In this position he made about 15 revolutions around the drum before the motion of the machinery could be effectually stopped by cutting off the water to the great wheel. When he was disentangled from the bands and taken down from the drum a huge wound was seen at the shoulder, but there was not more than a pint of blood lost. The collar-bone projected from the wound about half an inch, and hanging from the wound were two large nerves (probably the median and ulnar) more than 20 inches long. He was able to stand on his feet and actually walked a few steps; as his frock was opened, his arm, with a clot of blood, dropped to the floor. This boy made an excellent recovery. The space between the plastered ceiling and the drum in which the revolutions of the body had taken place was scarcely 7 1/2 inches wide. Horsbeck's case was of a negro of thirty-five who, while pounding resin on a 12-inch leather band, had his hand caught between the wheel and band. His hand, forearm, arm, etc., were rapidly drawn in, and he was carried around until his shoulder came to a large beam, where the body was stopped by resistance against the beam, fell to the floor, and the arm and scapula were completely avulsed and carried on beyond the beam. In this case, also, the man experienced little pain, and there was comparatively little hemorrhage. Maclean reports the history of an accident to a man of twenty-three who had both arms caught between a belt and the shaft while working in a woolen factory, and while the machinery was in full operation. He was carried around the shaft with great velocity until his arms were torn off at a point about four inches below the shoulder-joint on each side. The patient landed on his feet, the blood spurting from each brachial artery in a large stream. His fellow-workmen, without delay, wound a piece of rope around each bleeding member, and the man recovered after primary amputation of each stump. Will gives an excellent instance of avulsion of the right arm and scapula in a girl of eighteen, who was caught in flax-spinning machinery. The axillary artery was seen lying in the wound, pulsating feebly, but had been efficiently closed by the torsion of the machinery. The girl recovered.
Additional cases of avulsion of the upper extremity are reported by Aubinais, Bleynie, Charles, George, James, Jones, Marcano, Belchier, Braithwaite, and Hendry.
Avulsion of the Lower Extremity.—The symptoms following avulsion of the upper extremity are seen as well in similar accidents to the leg and thigh, although the latter are possibly the more fatal. Horlbeck quotes Benomont's description of a small boy who had his leg torn off at the knee by a carriage in motion; the child experienced no pain, and was more concerned about the punishment he expected to receive at home for disobedience than about the loss of his leg. Carter speaks of a boy of twelve who incautiously put the great toe of his left foot against a pinion wheel of a mill in motion. The toe was fastened and drawn into the mill, the leg following almost to the thigh. The whole left leg and thigh, together with the left side of the scrotum, were torn off; the boy died as a result of his injuries.
Ashurst reported to the Pathological Society of Philadelphia the case of a child of nine who had its right leg caught in the spokes of a carriage wheel. The child was picked up unconscious, with its thigh entirely severed, and the bone broken off about the middle third; about three inches higher the muscles were torn from the sheaths and appeared as if cut with a knife. The great sciatic nerve was found hanging 15 inches from the stump, having given way from its division in the popliteal space. The child died in twelve hours. One of the most interesting features of the case was the rapid cooling of the body after the accident and prolongation of the coolness with slight variations until death ensued. Ashurst remarks that while the cutaneous surface of the stump was acutely sensitive to the touch, there was no manifestation of pain evinced upon handling the exposed nerve.
With reference to injuries to the sciatic nerve, Kuster mentions the case of a strong man of thirty, who in walking slipped and fell on his back. Immediately after rising to his feet he felt severe pain in the right leg and numbness in the foot. He was unable to stand, and was carried to his house, where Kuster found him suffering great pain. The diagnosis had been fracture of the neck of the femur, but as there was no crepitation and passive movements caused but little pain, Kuster suspected rupture of the sciatic nerve. The subsequent history of the case confirmed this diagnosis. The patient was confined to bed six weeks, and it was five months afterward before he was able to go about, and then only with a crutch and a stick.
Park mentions an instance of rupture of the sciatic nerve caused by a patient giving a violent lurch during an operation at the hip-joint.
The instances occasionally observed of recovery of an injured leg after extensive severance and loss of substance are most marvelous. Morton mentions a boy of sixteen, who was struck by one of the blades of a reaping machine, and had his left leg cut through about 1 1/4 inches above the ankle-joint. The foot was hanging by the portion of skin corresponding to the posterior quarter of the circumference of the leg, together with the posterior tibial vessels and nerves. These were the only structures escaping division, although the ankle-joint itself was intact. There was comparatively little hemorrhage and no shock; a ligature was applied to the vessels, the edges of the wound were drawn together by wire sutures, and the cut surfaces of the tibia were placed in as good apposition as possible, although the lower fragment projected slightly in front of the upper. The wound was dressed and healing progressed favorably; in three months the wound had filled up to such an extent that the man was allowed to go on crutches. The patient was discharged in five months, able to walk very well, but owing to the loss of the function of the extensor tendons the toes dragged.
Washington reports in full the case of a boy of eleven, who, in handing a fowling piece across a ditch, was accidentally shot. The contents of the gun were discharged through the leg above the ankle, carrying away five-sixths of the structure—at the time of the explosion the muzzle of the gun was only two feet away from his leg. The portions removed were more than one inch of the tibia and fibula (irregular fractures of the ends above and below), a corresponding portion of the posterior tibial muscle, and the long flexors of the great and small toes, as well as the tissue interposed between them and the Achilles tendon. The anterior tibial artery was fortunately uninjured. The remaining portions consisted of a strip of skin two inches in breadth in front of the wound, the muscles which it covered back of the wound, the Achilles tendon, and another piece of skin, barely enough to cover the tendon. The wound was treated by a bran-dressing, and the limb was saved with a shortening of but 1 1/2 inches.
There are several anomalous injuries which deserve mention. Markoe observed a patient of seventy-two, who ruptured both the quadriceps tendons of each patella by slipping on a piece of ice, one tendon first giving way, and followed almost immediately by the other. There was the usual depression immediately above the upper margin of the patella, and the other distinctive signs of the accident. In three months both tendons had united to such an extent that the patient was able to walk slowly. Gibney records a case in which the issue was not so successful, his patient being a man who, in a fall ten years previously, had ruptured the right quadriceps tendon, and four years later had suffered the same accident on the opposite side. As a result of his injuries, at the time Gibney saw him, he had completely lost all power of extending the knee-joint. Partridge mentions an instance, in a strong and healthy man, of rupture of the tendon of the left triceps cubiti, caused by a fall on the pavement. There are numerous cases in which the tendo Achillis has recovered after rupture,—in fact, it is unhesitatingly severed when necessity demands it, sufficient union always being anticipated. None of these cases of rupture of the tendon are unique, parallel instances existing in medical literature in abundance.
Marshall had under his observation a case in which the femoral artery was ruptured by a cart wheel passing over the thigh, and death ensued although there were scarcely any external signs of contusion and positively no fracture. Boerhaave cites a curious instance in which a surgeon attempted to stop hemorrhage from a wounded radial artery by the application of a caustic, but the material applied made such inroads as to destroy the median artery and thus brought about a fatal hemorrhage.
Spontaneous fractures are occasionally seen, but generally in advanced age, although muscular action may be the cause. There are several cases on record in which the muscular exertion in throwing a stone or ball, or in violently kicking the leg, has fractured one or both of the bones of an extremity. In old persons intracapsular fracture may be caused by such a trivial thing as turning in bed, and even a sudden twist of the ankle has been sufficient to produce this injury. In a boy of thirteen Storrs has reported fracture of the femur within the acetabulum. In addition to the causes enumerated, inflammation of osseous tissue, or osteoid carcinoma, has been found at the seat of a spontaneous fracture.
One of the most interesting subjects in the history of surgery is the gradual evolution of the rational treatment of dislocations. Possibly no portion of the whole science was so backward as this. Thirty-five centuries ago Darius, son of Hydaspis, suffered a simple luxation of the foot; it was not diagnosed in this land of Apis and of the deified discoverer of medicine. Among the wise men of Egypt, then in her acme of civilization, there was not one to reduce the simple luxation which any student of the present day would easily diagnose and successfully treat. Throughout the dark ages and down to the present century, the hideous and unnecessary apparatus employed, each decade bringing forth new types, is abundantly pictured in the older books on surgery; in some almost recent works there are pictures of windlasses and of individuals making superhuman efforts to pull the luxated member back—all of which were given to the student as advisable means of treatment.
Relative to anomalous dislocations the field is too large to be discussed here, but there are two recent ones worthy of mention. Bradley relates an instance of death following a subluxation of the right humerus backward on the scapula It could not be reduced because the tendon of the biceps lay between the head of the humerus and a piece of the bone which was chipped off.
Baxter-Tyrie reports a dislocation of the shoulder-joint, of unusual origin, in a man who was riding a horse that ran away up a steep hill. After going a few hundred yards the animal abated its speed, when the rider raised his hand to strike. Catching sight of the whip, the horse sprang forward, while the man felt an acute pain and a sense of something having given way at his shoulder. He did not fall off, but rode a little further and was helped to dismount. On examination a subcoracoid dislocation of the head of the humerus was found. The explanation is that as the weight of the whip was inconsiderable (four ounces) the inertia of the arm converted it into a lever of the first order. Instead of fulfilling its normal function of preventing displacement, the coraco-acromial arch acted as a fulcrum. The limb from the fingers to that point acted as the "long arm," and the head and part of the neck of the humerus served as the "short arm." The inertia of the arm, left behind as it were, supplied the power, while the ruptured capsular ligament and displacement of the head of the bone would represent the work done.
Congenital Dislocations.—The extent and accuracy of the knowledge possessed by Hippocrates on the subject of congenital dislocations have excited the admiration of modern writers, and until a comparatively recent time examples of certain of the luxations described by him had not been recorded. With regard, for instance, to congenital dislocations at the shoulder-joint, little or nothing was known save what was contained in the writings of Hippocrates, till R. M. Smith and Guerin discussed the lesion in their works.
Among congenital dislocations, those of the hips are most common—in fact, 90 per cent of all. They are sometimes not recognizable until after the lapse of months and sometimes for years, but their causes—faulty developments of the joint, paralysis, etc.—are supposed to have existed at birth. One or both joints may be involved, and according to the amount of involvement the gait is peculiar. As to the reduction of such a dislocation, the most that can be done is to diminish the deformity and functional disability by traction and palliative measures with apparatus. The normal structure of the joint does not exist, and therefore the dislocation admits of no reduction. Congenital dislocations of the shoulder are also seen, owing to faulty development of the glenoid fossa; and at the knee, the leg generally being in extreme hyperextension, the foot sometimes resting on the abdomen. Congenital luxation of the femora, when it appears in adult women is a prominent factor in dystocia. There is a dislocation found at birth, or occurring shortly after, due to dropsy of the joint in utero; and another form due to succeeding paralysis of groups of muscles about the joint.
The interesting instances of major amputations are so numerous and so well known as to need no comment here. Amputation of the hip with recovery is fast becoming an ordinary operation; at Westminster Hospital in London, there is preserved the right humerus and scapula, presenting an enormous bulk, which was removed by amputation at the shoulder-joint, for a large lymphosarcoma growing just above the clavicle. The patient was a man of twenty-two, and made a good recovery. Another similar preparation is to be seen in London at St. Bartholomew's Hospital.
Simultaneous, synchronous, or consecutive amputations of all the limbs have been repeatedly performed. Champeuois reports the case of a Sumatra boy of seven, who was injured to such an extent by an explosion as to necessitate the amputation of all his extremities, and, despite his tender age and the extent of his injuries, the boy completely recovered. Jackson, quoted by Ashhurst, had a patient from whom he simultaneously amputated all four limbs for frost-bite.
Muller reports a case of amputation of all four limbs for frost-bite, with recovery. The patient, aged twenty-six, while traveling to his home in Northern Minnesota, was overtaken by a severe snow storm, which continued for three days; on December 13th he was obliged to leave the stage in a snow-drift on the prairie, about 110 miles distant from his destination. He wandered over the prairie that day and night, and the following four days, through the storm, freezing his limbs, nose, ears, and cheeks, taking no food or water until, on December 16th, he was found in a dying condition by Indian scouts, and taken to a station-house on the road. He did not reach the hospital at Fort Ridgely until the night of December 24th—eleven days after his first exposure. He was almost completely exhausted, and, after thawing the ice from his clothes, stockings, and boots,—which had not been removed since December 13th,—it was found that both hands and forearms were completely mortified up to the middle third, and both feet and legs as far as the upper third; both knees over and around the patellae, and the alae and tip of the nose all presented a dark bluish appearance and fairly circumscribed swelling. No evacuation of the bowels had taken place for over two weeks, and as the patient suffered from singultus and constant pain over the epigastric region, a light cathartic was given, which, in twenty-four hours, gave relief. The four frozen limbs were enveloped in a solution of zinc chlorid. The frozen ears and cheeks healed in due time, and the gangrenous parts of the nose separated and soon healed, with the loss of the tip and parts of the alae, leaving the septum somewhat exposed. On January 10th the lines of demarcation were distinct and deep on all four limbs, though the patient, seconded by his wife, at first obstinately opposed operative interference; on January 13th, after a little hesitancy, the man consented to an amputation of the arms. This was successfully carried out on both forearms, at the middle third, the patient losing hardly any blood and complaining of little pain. The great relief afforded by this operation so changed his aversion to being operated upon that on the next day he begged to have both legs amputated in the same manner, which was done, three days afterward, with the same favorable result. After some minor complications the patient left for his home, perfectly recovered, June 9, 1866.
Begg of Dundee successfully performed quadruple amputation on a woman, the victim of idiopathic gangrene. With artificial limbs she was able to earn a livelihood by selling fancy articles which she made herself. This woman died in 1885, and the four limbs, mounted on a lay figure, were placed in the Royal College of Surgeons, in London. Wallace, of Rock Rapids, Iowa, has successfully removed both forearms, one leg, and half of the remaining foot, for frost-bite. Allen describes the case of a boy of eight who was run over by a locomotive, crushing his right leg, left foot, and left forearm to such an extent as to necessitate primary triple amputation at the left elbow, left foot, and right leg, the boy recovering. Ashhurst remarks that Luckie, Alexander, Koehler, Lowman, and Armstrong have successfully removed both legs and one arm simultaneously for frost-bite, all the patients making excellent recoveries in spite of their mutilations; he adds that he himself has successfully resorted to synchronous amputation of the right hip-joint and left leg for a railroad injury occurring in a lad of fifteen, and has twice synchronously amputated three limbs from the same patient, one case recovering.
Wharton reports a case of triple major amputation on a negro of twenty-one, who was run over by a train. His right leg was crushed at the knee, and the left leg crushed and torn off in the middle third; the right forearm and hand were crushed. In order to avoid chill and exposure, he was operated on in his old clothes, and while one limb was being amputated the other was being prepared. The most injured member was removed first. Recovery was uninterrupted.
There are two cases of spontaneous amputation worthy of record. Boerhaave mentions a peasant near Leyden, whose axillary artery was divided with a knife, causing great effusion of blood, and the patient fainted. The mouth of the vessel was retracted so far as to render ligature impossible, and the poor man was abandoned to what was considered an inevitable fate by his unenlightened attendants. Expecting to die every moment, he continued several days in a languid state, but the hemorrhage ceased spontaneously, and the arm decayed, shrunk, and dried into a mummified stump, which he carried about for quite a while. Rooker speaks of a fracture of the forearm, near the lower part of the middle third, in a patient aged fourteen. Incipient gangrene below the seat of fracture, with associate inflammation, developed; but on account of the increasing gangrene it was determined to amputate. On the fifth day the line of demarcation extended to the spine of the scapula, laying bare the bone and exposing the acromion process and involving the pectoral muscles. It was again decided to let Nature continue her work. The bones exfoliated, the spine and the acromial end of the scapula came away, and a good stump was formed. Figure 212 represents the patient at the age of twenty-eight.
By ingenious mechanical contrivances persons who have lost an extremity are enabled to perform the ordinary functions of the missing member with but slight deterioration. Artificial arms, hands, and legs have been developed to such a degree of perfection that the modern mechanisms of this nature are very unlike the cumbersome and intricate contrivances formerly used.
Le Progres Medical contains an interesting account of a curious contest held between dismembered athletes at Nogent-Sur-Marne, a small town in the Department of the Seine, in France. Responding to a general invitation, no less than seven individuals who had lost either leg or thigh, competed in running races for prizes. The enterprising cripples were divided into two classes: the cuissards, or those who had lost a thigh, and jambards, or those who had lost a leg; and, contrary to what might have been expected, the grand champion came from the former class. The distance in each race was 200 meters. M. Roullin, whose thigh, in consequence of an accident, was amputated in 1887, succeeded in traversing the course in the remarkable time of thirty seconds (about 219 yards); whereas M. Florrant, the speediest jambard, required thirty-six seconds to run the same distance; and was, moreover, defeated by two other cuissards besides the champion. The junior race was won in thirty-five seconds, and this curious day's sport was ended by a course de consolation, which was carried off in thirty-three seconds by M. Mausire, but whether he was a cuissard or a jambard was not stated.
On several occasions in England, cricket matches have been organized between armless and legless men. In Charles Dickens' paper, "All the Year Round," October 5, 1861, there is a reference to a cricket match between a one-armed eleven and a one-legged eleven. There is a recent report from De Kalb, Illinois, of a boy of thirteen who had lost both legs and one arm, but who was nevertheless enabled to ride a bicycle specially constructed for him by a neighboring manufacturer. With one hand he guided the handle bar, and bars of steel attached to his stumps served as legs. He experienced no trouble in balancing the wheel; it is said that he has learned to dismount, and soon expects to be able to mount alone; although riding only three weeks, he has been able to traverse one-half a mile in two minutes and ten seconds. While the foregoing instance is an exception, it is not extraordinary in the present day to see persons with artificial limbs riding bicycles, and even in Philadelphia, May 30, 1896, there was a special bicycle race for one-legged contestants.
The instances of interesting cases of foreign bodies in the extremities are not numerous. In some cases the foreign body is tolerated many years in this location. There are to-day many veterans who have bullets in their extremities. Girdwood speaks of the removal of a foreign body after twenty-five years' presence in the forearm. Pike mentions a man in India, who, at the age of twenty-two, after killing a wounded hare in the usual manner by striking it on the back of the neck with the side of the hand, noticed a slight cut on the hand which soon healed but left a lump under the skin. It gave him no trouble until two months before the time of report, when he asked to have the lump removed, thinking it was a stone. It was cut down upon and removed, and proved to be the spinous process of the vertebra of a hare. The bone was living and healthy and had formed a sort of arthrodial joint on the base of the phalanx of the little finger and had remained in this position for nearly twenty-two years.
White has described a case in which a nail broken off in the foot, separated into 26 splinters, which, after intense suffering, were successfully removed. There was a case recently reported of a man admitted to the Bellevue Hospital, New York, whose arm was supposed to have been fractured by an explosion, but instead of which 11 feet of lead wire were found in it by the surgeons. The man was a machinist in the employ of the East River Lead Co., and had charge of a machine which converted molten lead into wire. This machine consists of a steel box into which the lead is forced, being pressed through an aperture 1/8 inch in diameter by hydraulic pressure of 600 tons. Reaching the air, the lead becomes hard and is wound on a large wheel in the form of wire. Just before the accident this small aperture had become clogged, and the patient seized the projecting wire in his hand, intending to free the action of the machine, as he had previously done on many occasions, by a sharp, strong pull; but in so doing an explosion occurred, and he was hurled to the floor unconscious. While on the way to the hospital in the ambulance, he became conscious and complained of but little pain except soreness of the left arm about the elbow. The swelling, which had developed very rapidly, made it impossible for the surgeons to make an examination, but on the following day, when the inflammation had subsided sufficiently, a diagnosis of fracture of the bones of the arm was made. There was no external injury of the skin of any magnitude, and the surgeons decided to cut down on the trifling contusion, and remove what appeared to be a fragment of bone, lodged slightly above the wrist. An anesthetic was administered, and an incision made, but to the amazement of the operators, instead of bone, a piece of wire one inch in length and 1/8 inch in diameter was removed. On further exploration piece after piece of the wire was taken out until finally the total length thus removed aggregated 11 feet, the longest piece measuring two feet and the shortest 1/4 inch. The wire was found imbedded under the muscles of the arm, and some of it had become wedged between the bones of the forearm. Probably the most remarkable feature of this curious accident was the fact that there was no fracture or injury to the bone, and it was thought possible that the function of the arm would be but little impaired.
Tousey reports a case of foreign body in the axilla that was taken for a necrotic fragment of the clavicle. The patient was a boy of sixteen, who climbed up a lamp-post to get a light for his bicycle lamp; his feet slipped off the ornamental ledge which passed horizontally around the post about four feet from the ground, and he fell. In the fall a lead pencil in his waistcoat pocket caught on the ledge and was driven into the axilla, breaking off out of sight. This was supposed to be a piece of the clavicle, and was only discovered to be a pencil when it was removed six weeks after.
There are several diseases of the bone having direct bearing on the anomalies of the extremities which should have mention here. Osteomalacia is a disease of the bones in adult life, occurring most frequently in puerperal women, but also seen in women not in the puerperal state, and in men. It is characterized by a progressive softening of the bone-substance, from a gradual absorption of the lime salts, and gives rise to considerable deformity, and occasionally to spontaneous fracture.
Rachitis or rickets is not a disease of adult life, but of infancy and childhood, and never occurs after the age of puberty. 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 principal 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 circumstances the humerus and femur appear to be the bones most likely to break; there is an associate deformity of the head, known as "craniotabes," together with pigeon-breast and various spinal curvature. The accompanying illustration 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 "adventitious joints" were the result of imperfect ossification, or, in other words, of motion before ossification was completed.
Analogous 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 assignable 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 circumference. 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 analyzed 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.
Injuries of the lung or bronchus are always serious, but contrary to the general idea, recovery after extensive wound of the lung is quite a common occurrence. Even the older writers report many instances of remarkable recoveries from lung-injuries, despite the primitive and dirty methods of treatment. A review of the literature previous to this century shows the names of Arcaeus, Brunner, Collomb, Fabricius Hildanus, Vogel, Rhodius, Petit, Guerin, Koler, Peters, Flebbe, and Stalpart, as authorities for instances of this nature. In one of the journals there is a description of a man who was wounded by a broad-sword thrust in the mediastinum. After death it was found that none of the viscera were wounded, and death was attributed to the fact that the in-rush of air counterbalancing the pressure within the lungs left them to their own contractile force, with resultant collapse, obstruction to the circulation, and death. It is said that Vesalius demonstrated this condition on the thorax of a pig.
Gooch gives an instance of a boy of thirteen who fell from the top of a barn upon the sharp prow of a plough, inflicting an oblique wound from the axilla to below the sternum, slightly above the insertion of the diaphragm. Several ribs were severed, and the left thoracic cavity was wholly exposed to view, showing the lungs, diaphragm, and pericardium all in motion. The lungs soon became gangrenous, and in this horrible state the patient lived twelve days. One of the curious facts noticed by the ancient writers was the amelioration of the symptoms caused by thoracic wounds after hemorrhage from other locations; and naturally, in the treatment of such injuries, this circumstance was used in advocacy of depletion. Monro speaks of a gentleman who was wounded in a duel, and who had all the symptoms of hemothorax; his condition was immediately relieved by the evacuation of a considerable quantity of bloody matter with the urine. Swammerdam records a similar case, and Fabricius ab Aquapendente noticed a case in which the opening in the thorax showed immediate signs of improvement after the patient voided large quantities of bloody urine. Glandorp also calls attention to the foregoing facts. Nicolaus Novocomensis narrates the details of the case of one of his friends, suffering from a penetrating wound of the thorax, who was relieved and ultimately cured by a bloody evacuation with the stool.
There is an extraordinary recovery reported in a boy of fifteen who, by falling into the machinery of an elevator, was severely injured about the chest. There were six extensive lacerations, five through the skin about six inches long, and one through the chest about eight inches long. The 3d, 4th, 5th, and 6th ribs were fractured and torn apart, and about an inch of the substance of the 4th rib was lost. Several jagged fragments were removed; a portion of the pleura, two by four inches, had been torn away, exposing the pericardium and the left lung, and showing the former to have been penetrated and the latter torn. The lung collapsed completely, and for three or four months no air seemed to enter it, but respiration gradually returned. The lacerated integument could only be closed approximately by sutures. It is worthy of remark that, although extremely pale, the patient complained of but little pain, and exhibited only slight symptoms of shock. The pleural cavity subsequently filled with a dirty serum, but even this did not interfere with the healing of the wound and the restoration of the lung; the patient recovered without lateral curvature.
Bartholf reports a case of rapid recovery after perforating wound of the lung. The pistol-ball entered the back 1 1/2 inches to the right of the spinous process of the 6th dorsal vertebra, and passed upward and very slightly inward toward the median line. Its track could be followed only 1 1/4 inches. Emphysema appeared fifteen minutes after the reception of the wound, and soon became pronounced throughout the front and side of the neck, a little over the edge of the lower jaw, and on the chest two inches below the sternum and one inch below the clavicle. In four hours respiration became very frequent, short, and gasping, the thoracic walls and the abdomen scarcely moving. The man continued to improve rapidly, the emphysema disappeared on the seventh day, and eighteen days after the reception of the wound he was discharged. There was slight hemorrhage from the wound at the time, but the clot dried and closed the wound, and remained there until it was removed on the morning of his discharge, leaving a small, dry, white cicatrix.
Loss of Lung-tissue.—The old Amsterdam authority, Tulpius, has recorded a case in which a piece of lung of about three fingers' breadth protruded through a large wound of the lung under the left nipple. This wound received no medical attention for forty-eight hours, when the protruding portion of lung was thought to be dead, and was ligated and cut off; it weighed about three ounces. In about two weeks the wound healed with the lung adherent to it and this condition was found six years later at the necropsy of this individual. Tulpius quoted Celaus and Hippocrates as authorities for the surgical treatment of this case. In 1787 Bell gave an account of a case in which a large portion of the lung protruded and was strangulated by the edges of the thoracic wound, yet the patient made a good recovery. Fabricius Hildanus and Ruysch record instances of recovery in which large pieces of lung have been cut off; and it is said that with General Wolfe at Quebec there was another officer who was shot through the thorax and who recovered after the removal of a portion of the lung. In a letter to one of his medical friends Roscius says that he succeeded in cutting off part of a protruding, livid, and gangrenous lung, after a penetrating wound of the chest, with a successful result. Hale reports a case of a penetrating stab-wound in which a piece of lung was removed from a man of twenty-five.
Tait claims that surgical treatment, as exemplified by Biondi's experiment in removing portions of lung from animals, such as dogs, sheep, cats, etc., is not practical; he adds that his deductions are misleading, as the operation was done on healthy tissue and in deep and narrow-chested animals. Excision of diseased portions of the lung has been practised by Kronlein (three cases), Ruggi of Bologna (two cases), Block, Milton, Weinlechner; one of Kronlein's patients recovered and Milton's survived four months, but the others promptly succumbed after the operation. Tuffier is quoted as showing a patient, aged twenty-nine, upon whom, for beginning tuberculosis, he had performed pneumonectomy four years before. At the operation he had removed the diseased area at the apex of the right lung, together with sound tissue for two cm. in every direction. Tuffier stated that the result of his operation had been perfectly successful and the patient had shown no suspicious symptoms since.
Rupture of the Lung Without Fracture.—It is quite possible for the lung to be ruptured by external violence without fracture of the ribs; there are several such cases on record. The mechanism of this rare and fatal form of injury has been very aptly described by Gosselin as due to a sudden pressure exerted on the thoracic wall at the moment of full inspiration, there being a spasm of the glottis or obstruction of the larynx, in consequence of which the lung bursts. An extravasation of air occurs, resulting in the development of emphysema, pneumothorax, etc. Subsequently pleurisy, pneumonia, or even pus in the pleural cavity often result. Hemoptysis is a possible, but not a marked symptom. The mechanism is identical with that of the bursting of an inflated paper bag when struck by the hand. Other observers discard this theory of M. Gosselin and claim that the rupture is due to direct pressure, as in the cases in which the heart is ruptured without fracture of the ribs. The theory of Gosselin would not explain these cardiac ruptures from external violence on the thoracic walls, and, therefore, was rejected by some. Pare, Morgagni, Portal, Hewson Smith, Dupuytren, Laennec, and others mention this injury. Gosselin reports two cases terminating in recovery. Ashurst reports having seen three cases, all of which terminated fatally before the fifth day; he has collected the histories of 39 cases, of which 12 recovered. Otis has collected reports of 25 cases of this form of injury from military practice exclusively. These were generally caused by a blow on the chest, by a piece of shell, or other like missile. Among the 25 cases there were 11 recoveries. As Ashhurst very justly remarks, this injury appears more fatal in civil than in military life.
Pyle reports a case successfully treated, as follows:—
"Lewis W., ten years old, white, born in Maryland, and living now in the District of Columbia, was brought in by the Emergency Hospital ambulance, on the afternoon of November 10th, with a history of having been run over by a hose-cart of the District Fire Department. The boy was in a state of extreme shock, having a weak, almost imperceptible pulse; his respirations were shallow and rapid, and his temperature subnormal. There were no signs of external injury about his thoracic cavity and no fracture of the ribs could be detected, although carefully searched for; there was marked emphysema; the neck and side of the face were enormously swollen with the extravasated air; the tissues of the left arm were greatly infiltrated with air, which enabled us to elicit the familiar crepitus of such infiltration when an attempt at the determination of the radial pulse was made. Consciousness was never lost. There were several injuries to the face and scalp; and there was hemorrhage from the nose and mouth, which was attributed to the fact that the patient had fallen on his face, striking both nose and lip. This was confirmed subsequently by the absence of any evidences of hemoptysis during the whole period of convalescence. The saliva was not even blood-streaked; therefore, it can be said with verity that there was no hemoptysis. Shortly after admission the patient reacted to the stimulating treatment, his pulse became stronger, and all evidences of threatened collapse disappeared. He rested well the first night and complained of no pain, then or subsequently. The improvement was continuous. The temperature remained normal until the evening of the fifth day, when it rose to 102.2 degrees, end again, on the evening of the sixth, to 102.3 degrees. This rise was apparently without significance as the patient at no time seemed disturbed by it. On the eighth day the temperature again reached the normal and has since remained there. The boy is apparently well now, suffers no inconvenience, and has left the hospital, safe from danger and apparently free from any pulmonary embarrassment. He uses well-developed diaphragmatic breathing which is fully sufficient."
Pollock reports the case of a boy of seven, whose lung was ruptured by a four-wheeled cab which ran over him. He was discharged well in thirty-two days. Bouilly speaks of recovery in a boy of seventeen, after a rupture of the lung without fracture. There are several other interesting cases of recovery on record.
There are instances of spontaneous rupture of the lung, from severe cough. Hicks speaks of a child of ten months suffering with a severe cough resembling pertussis, whose lung ruptured about two weeks after the beginning of the cough, causing death on the second day. Ferrari relates a curious case of rupture of the lung from deep inspiration.
Complete penetration or transfixion of the thoracic cavity is not necessarily fatal, and some marvelous instances of recovery after injuries of this nature, are recorded. Eve remarks that General Shields was shot through the body by a discharge of a cannon at Cerro Gordo, and was given up as certain to die. The General himself thought it was grape-shot that traversed his chest. He showed no signs of hemoptysis, and although in great pain, was able to give commands after reception of the wound. In this case, the ball had evidently entered within the right nipple, had passed between the lungs, through the mediastinum, emerging slightly to the right of the spine. Guthrie has mentioned a parallel instance of a ball traversing the thoracic cavity, the patient completely recovering after treatment. Girard, Weeds, Meacham, Bacon, Fryer and others report cases of perforating gunshot wounds of the chest with recovery.
Sewell describes a case of transfixion of the chest in a youth of eighteen. After mowing and while carrying his scythe home, the patient accidentally fell on the blade; the point passed under the right axilla, between the 3d and 4th right ribs, horizontally through the chest, and came out through corresponding ribs of the opposite side, making a small opening. He fell to the ground and lay still until his brother came to his assistance; the latter with great forethought and caution carefully calculated the curvature of the scythe blade, and thus regulating his direction of tension, successfully withdrew the instrument. There was but little hemoptysis and the patient soon recovered. Chelius records an instance of penetration of the chest by a carriage shaft, with subsequent recovery. Hoyland mentions a man of twenty-five who was discharging bar-iron from the hold of a ship; in a stooping position, preparatory to hoisting a bundle on deck, he was struck by one of the bars which pinned him to the floor of the hold, penetrating the thorax, and going into the wood of the flooring to the extent of three inches, requiring the combined efforts of three men to extract it. The bar had entered posteriorly between the 9th and 10th ribs of the left side, and had traversed the thorax in an upward and outward direction, coming out anteriorly between the 5th and 6th ribs, about an inch below and slightly external to the nipple. There was little constitutional disturbance, and the man was soon discharged cured. Brown records a case of impalement in a boy of fourteen. While running to a fire, he struck the point of the shaft of a carriage, which passed through his left chest, below the nipple. There was, strangely, no hemorrhage, and no symptoms of so severe an injury; the boy recovered.
There is deposited in the Museum of the Royal College of Surgeons in London, a mast-pivot, 15 inches in length and weighing between seven and eight pounds, which had passed obliquely through the body of a sailor. The specimen is accompanied by a colored picture of the sufferer himself in two positions. The name of the sailor was Taylor, and the accident occurred aboard a brig lying in the London docks. One of Taylor's mates was guiding the pivot of the try-sail into the main boom, when a tackle gave way. The pivot instantly left the man's hand, shot through the air point downward striking Taylor above the heart, passing out lower down posteriorly, and then imbedded itself in the deck. The unfortunate subject was carried at once to the London Hospital, and notwithstanding his transfixion by so formidable an instrument, in five months Taylor had recovered sufficiently to walk, and ultimately returned to his duties as a seaman.
In the same museum, near to this spike, is the portion of a shaft of the carriage which passed through the body of a gentleman who happened to be standing near the vehicle when the horse plunged violently forward, with the result that the off shaft penetrated his body under the left arm, and came out from under the right arm, pinning the unfortunate man to the stable door. Immediately after the accident the patient walked upstairs and got in bed; his recovery progressed uninterruptedly, and his wounds were practically healed at the end of nine weeks; he is reported to have lived eleven years after this terrible accident.
In the Indian Medical Gazette there is an account of a private of thirty-five, who was thrown forward and off his horse while endeavoring to mount. He fell on a lance which penetrated his chest and came out through the scapula. The horse ran for about 100 yards, the man hanging on and trying to stop him. After the extraction of the lance the patient recovered. Longmore gives an instance of complete transfixion by a lance of the right side of the chest and lung, the patient recovering. Ruddock mentions cases of penetrating wounds of both lungs with recovery.
There is a most remarkable instance of recovery after major thoracic wounds recorded by Brokaw. In a brawl, a shipping clerk received a thoracic wound extending from the 3d rib to within an inch of the navel, 13 1/2 inches long, completely severing all the muscular and cartilaginous structures, including the cartilages of the ribs from the 4th to the 9th, and wounding the pleura and lung. In addition there was an abdominal wound 6 1/2 inches long, extending from the navel to about two inches above Poupart's ligament, causing almost complete intestinal evisceration. The lung was partially collapsed. The cartilages were ligated with heavy silk, and the hemorrhage checked by ligature and by packing gauze in the inter-chondral spaces. The patient speedily recovered, and was discharged in a little over a month, the only disastrous result of his extraordinary injuries being a small ventral hernia.
In wounds of the diaphragm, particularly those from stabs and gunshot injuries, death is generally due to accompanying lesions rather than to injury. Hollerius, and Alexander Benedictus, made a favorable diagnosis of wounds made in the fleshy portions of the diaphragm, but despaired of those in the tendinous portions. Bertrand, Fabricius Hildanus, la Motte, Ravaton, Valentini, and Glandorp, record instances of recovery from wounds of the diaphragm.
There are some peculiar causes of diaphragmatic injuries on record, laughter, prolonged vomiting, excessive eating, etc., being mentioned. On the other hand, in his "Essay on Laughter (du Ris)," Joubert quotes a case in which involuntary laughter was caused by a wound of the diaphragm; the laughter mentioned in this instance was probably caused by convulsive movements of the diaphragm, due to some unknown irritation of the phrenic nerve. Bremuse gives an account of a man who literally split his diaphragm in two by the ingestion of four plates of potato soup, numerous cups of tea and milk, followed by a large dose of sodium bicarbonate to aid digestion. After this meal his stomach swelled to an enormous extent and tore the diaphragm on the right side, causing immediate death.
The diaphragm may be ruptured by external violence (a fall on the chest or abdomen), or by violent squeezing (railroad accidents, etc.), or according to Ashhurst, by spasmodic contraction of the part itself. If the injury is unaccompanied by lesion of the abdominal or thoracic viscera, the prognosis is not so unfavorable as might be supposed. Unless the laceration is extremely small, protrusion of the stomach or some other viscera into the thoracic cavity will almost invariably result, constituting the condition known as internal or diaphragmatic hernia. Pare relates the case of a Captain who was shot through the fleshy portion of the diaphragm, and though the wound was apparently healed, the patient complained of a colicky pain. Eight months afterward the patient died in a violent paroxysm of this pain. At the postmortem by Guillemeau, a man of great eminence and a pupil of Pare, a part of the colon was found in the thorax, having passed through a wound in the diaphragm. Gooch saw a similar case, but no history of the injury could be obtained. Bausch mentions a case in which the omentum, stomach, and pancreas were found in the thoracic cavity, having protruded through an extensive opening in the diaphragm. Muys, Bonnet, Blancard, Schenck, Sennert, Fantoni, and Godefroy record instances in which, after rupture of the diaphragm, the viscera have been found in the thorax; there are many modern cases on record. Internal hernia through the diaphragm is mentioned by Cooper, Bowles, Fothergill, Monro, Ballonius, Derrecagiax, and Schmidt. Sir Astley Cooper mentioned a case of hernia ventriculi from external violence, wherein the diaphragm was lacerated without any fracture of the ribs. The man was aged twenty-seven, and being an outside passenger on a coach (and also intoxicated), when it broke down he was projected some distance, striking the ground with considerable force. He died on the next day, and the diagnosis was verified at the necropsy, the opening in the diaphragm causing stricture of the bowel.
Postempski successfully treated a wound of the diaphragm complicated with a wound of the omentum, which protruded between the external opening between the 10th and 11th ribs; he enlarged the wound, forced the ribs apart, ligated and cut off part of the omentum, returned its stump to the abdomen, and finally closed both the wound in the diaphragm and the external wound with sutures. Quoted by Ashhurst, Hunter recorded a case of gunshot wound, in which, after penetrating the stomach, bowels, and diaphragm the ball lodged in the thoracic cavity, causing no difficulty in breathing until shortly before death, and even then the dyspnea was mechanical—from gaseous distention of the intestines.
Peritonitis in the thoracic cavity is a curious condition which may be brought about by a penetrating wound of the diaphragm. In 1872 Sargent communicated to the Boston Society for Medical Improvement an account of a postmortem examination of a woman of thirty-seven, in whom he had observed major injuries twenty years before. At that time, while sliding down some hay from a loft, she was impaled on the handle of a pitchfork which entered the vagina, penetrated 22 inches, and was arrested by an upper left rib, which it fractured; further penetration was possibly prevented by the woman's feet striking the floor. Happily there was no injury to the bladder, uterus, or intestines. The principal symptoms were hemorrhage from the vagina and intense pain near the fractured rib, followed by emphysema. The pitchfork-handle was withdrawn, and was afterward placed in the museum of the Society, the abrupt bloody stain, 22 inches from the rounded end, being plainly shown. During twenty years the woman could never lie on her right side or on her back, and for half of this time she spent most of the night in the sitting position. Her last illness attracted little attention because her life had been one of suffering. After death it was found that the cavity in the left side of the chest was entirely filled with abdominal viscera. The opening in the diaphragm was four inches in diameter, and through it had passed the stomach, transverse colon, a few inches of the descending colon, and a considerable portion of the small intestines. The heart was crowded to the right of the sternum and was perfectly healthy, as was also the right lung. The left lung was compressed to the size of a hand. There were marked signs of peritonitis, and in the absence of sufficient other symptoms, it could be said that this woman had died of peritonitis in the left thoracic cavity.
Extended tolerance of foreign bodies loose in the thoracic cavity has been noticed. Tulpins mentions a person who had a sponge shut up in his thoracic cavity for six weeks; it was then voided by the mouth, and the man recovered. Fabricius Hildanus relates a similar instance in which a sponge-tent was expelled by coughing. Arnot reports a case in which a piece of iron was found in a cyst in the thorax, where it had remained for fourteen years. Leach gives a case in which a bullet was impacted in the chest for forty-two years. Snyder speaks of a fragment of knife-blade which was lodged in the chest twelve years and finally coughed up.
Foreign Bodies in the Bronchi.—Walnut kernels, coins, seeds, beans, corks, and even sponges have been removed from the bronchi. In the presence of Sir Morrell Mackenzie, Johnston of Baltimore removed a toy locomotive from the subglottic cavity by tracheotomy and thyreotomy. The child had gone to sleep with the toy in his mouth and had subsequently swallowed it. Eldredge presented a hopeless consumptive, who as a child of five had swallowed an umbrella ferrule while whistling through it, and who expelled it in a fit of coughing twenty-three years after. Eve of Nashville mentions a boy who placed a fourpenny nail in a spool to make a whistle, and, by a violent inspiration, drew the nail deep into the left bronchus. It was removed by tracheotomy. Liston removed a large piece of bone from the right bronchus of a woman, and Houston tells of a case in which a molar tooth was lodged in a bronchus causing death on the eleventh day. Warren mentions spontaneous expulsion of a horse-shoe nail from the bronchus of a boy of two and one-half years. From Dublin, in 1844, Houston reports the case of a girl of sixteen who inhaled the wooden peg of a small fiddle and in a fit of coughing three months afterward expelled it from the lungs. In 1849 Solly communicated the case of a man who inhaled a pebble placed on his tongue to relieve thirst. On removal this pebble weighed 144 grains. Watson of Murfreesboro removed a portion of an umbrella rib from a trachea, but as he failed to locate or remove the ferrule, the case terminated fatally. Brigham mentions a child of five who was seized with a fit of coughing while she had a small brass nail in her mouth; pulmonary phthisis ensued, and in one year she died. At the postmortem examination the nail was found near the bifurcation of the right bronchus, and, although colored black, was not corroded.
Marcacci reported an observation of the removal of a bean from the bronchus of a child of three and a half years. The child swallowed the bean while playing, immediately cried, and became hoarse. No one having noticed the accident, a diagnosis of croup was made and four leeches were applied to the neck. The dyspnea augmented during the night, and there was a whistling sound with each respiratory movement. On the next day the medical attendants suggested the possibility of a foreign body in the larynx. Tracheotomy was performed but the dyspnea continued, showing that the foreign body was lodged below the incision. The blood of one of the cut vessels entered the trachea and caused an extra paroxysm of dyspnea, but the clots of blood were removed by curved forceps. Marcacci fils practised suction, and placed the child on its head, but in vain. A feather was then introduced in the wound with the hope that it would clean the trachea and provoke respiration; when the feather was withdrawn the bean followed. The child was much asphyxiated, however, and five or six minutes elapsed before the first deep inspiration. The wound was closed, the child recovered its voice, and was well four days afterward. Annandale saw a little patient who had swallowed a bead of glass, which had lodged in the bronchus. He introduced the handle of a scalpel into the trachea, producing sufficient irritation to provoke a brusque expiration, and at the second attempt the foreign body was expelled. Hulke records the case of a woman, the victim of a peculiar accident happening during the performance of tracheotomy, for an affection of the larynx. The internal canule of the tracheotomy-tube fell into the right bronchus, but was removed by an ingenious instrument extemporaneously devised from silver wire. A few years ago in this country there was much public excitement and newspaper discussion over the daily reports which came from the bedside of a gentleman who had swallowed a cork, and which had become lodged in a bronchus. Tracheotomy was performed and a special corkscrew devised to extract it, but unfortunately the patient died of slow asphyxiation and exhaustion. Herrick mentions the case of a boy of fourteen months who swallowed a shawl-pin two inches long, which remained in the lungs four years, during which time there was a constant dry and spasmodic cough, and corresponding depression and emaciation. When it was ultimately coughed up it appeared in one large piece and several smaller ones, and was so corroded as to be very brittle. After dislodgment of the pin there was subsidence of the cough and rapid recovery.
Lapeyre mentions an elderly gentleman who received a sudden slap on the back while smoking a cigarette, causing him to start and take a very deep inspiration. The cigarette was drawn into the right bronchus, where it remained for two months without causing symptoms or revealing its presence. It then set up a circumscribed pneumonia and cardiac dropsy which continued two months longer, at which time, during a violent fit of coughing, the cigarette was expelled enveloped in a waxy, mucus-like matter. Louis relates the case of a man who carried a louis-d'or in his lung for six and a half years.
There is a case on record of a man who received a gunshot wound, the ball entering behind the left clavicle and passing downward and across to the right clavicle. Sometime afterward this patient expectorated two pieces of bone and a piece of gum blanket in which he was enveloped at the time of the injury. Carpenter describes a case of fatal pleuritis, apparently due to the presence of four artificial teeth which had been swallowed thirteen years before.
Cardiac Injuries.—For ages it has been the common opinion relative to injuries of the heart that they are necessarily fatal and that, as a rule, death immediately follows their reception. Notwithstanding this current belief a careful examination of the literature of medicine presents an astounding number of cases in which the heart has been positively wounded, and the patients have lived days, months, and even recovered; postmortem examination, by revealing the presence of cicatrices in the heart, confirming the original diagnosis. This question is one of great interest as, in recent years, there has been constant agitation of the possibility of surgical procedures in cardiac as well as cerebral injuries. Del Vecchio has reported a series of experiments on dogs with the conclusion that in case of wounds in human beings suture of the heart is a possible operation. In this connection he proposes the following operative procedure: Two longitudinal incisions to be made from the lower border of the 3d rib to the upper border of the 7th rib, one running along the inner margin of the sternum, the other about ten mm. inside the nipple-line. These incisions are joined by a horizontal cut made in the fourth intercostal space. The 4th, 5th, and 6th ribs and cartilages are divided and the outer cutaneous flaps turned up; pushing aside the pleura with the finger, expose the pericardium and incise it longitudinally; suture the heart-wound by interrupted sutures. Del Vecchio adds that Fischer has collected records of 376 cases of wounds of the heart with a mortality two to three minutes after the injury of 20 per cent. Death may occur from a few seconds to nine months after the accident. Keen and Da Costa quote Del Vecchio, and, in comment on his observations, remark that death in cases of wound of the heart is due to pressure of effused blood in the pericardial sac, and, because this pressure is itself a cheek to further hemorrhage, there seems, as far as hemorrhage is concerned, to be rather a question whether operative interference may not be itself more harmful than beneficial. It might be added that the shock to the cardiac action might be sufficient to check it, and at present we would have no sure means of starting pulsation if once stopped. In heart-injuries, paracentesis, followed, if necessary, by incision of the pericardium, is advised by some surgeons.
Realizing the fatality of injuries of the heart, in consequence of which almost any chance by operation should be quickly seized by surgeons rather than trust the lives of patients to the infinitesimal chance of recovery, it would seem that the profession should carefully consider and discuss the feasibility of any procedure in this direction, no matter how hypothetic.
Hall states that his experience in the study of cardiac wounds, chiefly on game-animals, would lead him to the conclusion that transverse wounds the lower portions of the heart, giving rise to punctures rather than extensive lacerations, do not commonly cause cessation of life for a time varying from some considerable fraction of a minute to many minutes or even hours, and especially if the puncture be valvular in character, so as to prevent the loss of much blood. However, if the wound involve the base of the organ, with extensive laceration of the surrounding parts, death is practically instantaneous. It would seem that injury to the muscular walls of the heart is much less efficient in the production of immediate death than destruction of the cardiac nervous mechanism, serious irritation of the latter producing almost instantaneous death from shock. In addition, Hall cites several of the instances on which he based his conclusions. He mentions two wild geese which flew respectively 1/4 and 3/4 of a mile after having been shot through the heart, each with a pellet of BB shot, the base in each instance being uninjured; in several instances antelope and deer ran several rods after being shot with a rifle ball in a similar manner; on the other hand, death was practically instantaneous in several of these animals in which the base of the heart was extensively lacerated. Again, death may result instantaneously from wounds of the precordial region, or according to Erichsen, if held directly over the heart, from the discharge of a pistol containing powder alone, a result occasionally seen after a blow on the precordial region. It is well, however, to state that in times of excitement, one may receive an injury which will shortly prove fatal, and yet not be aware of the fact for some time, perhaps even for several minutes. It would appear that the nervous system is so highly tuned at such times, that it does not respond to reflex irritations as readily as in the absence of excitement.