CHAPTER XII. LUNG WOUNDS, AND THEIR COMPLICATIONS. In this portion of the treatise, I shall briefly allude to the complication of lung-wounds, with 1. The Heart, and large vessels. Here would properly come observations upon wounds of the pericardium and of the heart; but as no case came under my immediate observation, I refrain from entering upon the interesting subject, observing merely, that wounds of the heart are not now considered, as in ancient times, instantly and invariably fatal ; it is yet to be shown how deeply and seriously the heart will bear external injury without destruction to life, for it is certain that it will bear more injury than was formerly supposed. The following case applies to this point: it was communicated to me by Dr. Aitkin, late Pathologist to the Army in the East, and author of the Practice of Physic; as also case No. 14: “ A boy, about 14 years of age, standing near to a party of recruits being drilled in the use of firearms, on the 24th of September, 1854, had the contents accidentally of one of the rifles lodged in his chest. He was taken to the Royal Infirmary of Glasgow, near which the accident occurred, and survived three days.” I give only the portion of the examination which applies to the present question:-“ The pericardium was entire ; but on opening into its cavity, the serous surface corresponding in position to the injured part of the lung, was somewhat red from blood-vessels ramifying over its surface. A lacerated wound extended for about half an inch in length upon the anterior and lateral surface of the left ventricle, near to, and parallel to the septum.” Museum Catalogue, Nos. 8, 9, 10, 11. In the examination of Experiment 10, page 71, we could not be certain whether we had detected an opening in the pericardium ; but the substance of the heart being wounded, we considered it very improbable that the heart could have been wounded without the pericardium having been opened, and attributed the non-discovery to defective observation. But the report of the foregoing case shows that the heart may be ruptured and the pericardium nevertheless entire; and consequently in the foregoing experiment this singular pathologico-anato nev mical fact may have been present. A case of bayonet wound of the heart is related in vol. ii, page 58 of the Medico-Chirurgical Transactions. A curious case of wound of the heart is related in the Medical Circular of 27th October, 1857, page 173.. The ancients knew that the wounds of the pericardium were not of themselves fatal, but from the consequent injury to surrounding parts : several of my cases illustrate this point. I have not met with a case of wound of the aorta or cavæ in my post mortem examinations, nor is mention made of an instance of this kind in the Director-General's Report. There is no doubt that the resilient power of the arterial coats, and also the elastic nature of the coats of the large veins will, in a great measure, explain this curious exemption from injury. The case of wound of the subclavian vein, reported by Mr. Blenkins at page 13, is a solitary recorded instance. This exemption may, however, be more ideal than real. The cause of death of most, if not all, of the killed on the field of battle is probably from torn and ruptured blood-vessels. The two following cases are given specially as “opening into the mediastinum.” In No. 14, other interesting pathological appearances were observed, which suggest the inquiry, whether the vomiting stated to have been present depended upon injury to the phrenic nerve? The enlarged stomach noted in this case was observed by me in several other cases. The observation made as to the distended auricle, will require future verification before a physiological datum can be drawn. CASE 14. James Fleming, aged 22, 18th regiment, wounded on the 18th of June. Ball passed through the biceps muscle of the right arm, revolved round the bone, and entered the thorax between the third and fourth ribs. Exit one inch below left mamma fracturing sternum. Pulse 100, full; respiration 25. Hæmoptysis. Ordered a grain of calomel, half a grain of antimony, three grains of hyoscyamus, three times a day. 22nd June. No change; medicine intermitted ; and bled to forty ounces. 24th. Pulse 90, with strong heart's impulse. A peculiar watery crackling sound is heard over middle of sternum at systole of heart. An opiate ordered. 27th. To have ten drops of the tincture of digitalis three times a day. 6th July. The digitalis seemed to have no power over the action of the heart, which varied in its pulsations from 94 to 104; respirations from 28 to 44. To-day, has pain in right side; friction sound audible three inches below left nipple. A blister applied; and a pill of two grains of calomel, and a quarter of a grain of opium ordered every three hours. 7th. Pulse 92 ; respirations 28. An incision made over centre of sternum, and several loose e er portions of bone removed. Pill intermitted. A large artery can be felt pulsating upon introducing the little finger into the wound. 11th. More portions of bone removed. 12th. Pus and serum seen at the bottom of the wound. This fluid is drawn inwards on inspiration and forced outwards on expiration. 13th. Frequent vomiting and diarrhea. Nutritious injections ordered. 14th. Incessant vomiting. A circular opening in pericardium, a quarter of an inch in diameter, seen at the bottom of the wound, and from which proceeds a whiff of air on expiration. Died at 11 A.M. Examination two hours after death. A quantity of burrowed pus escaped upon making an incision across the wound in the sternum ; at this spot the bone denuded of periosteum. The cartilages of the second, third, and fourth ribs, and corresponding portions of sternum, carried away. The posterior wall of the anterior mediastinum coated with a greenish coloured lymph. An opening existed, five lines in diameter, into the pericardial cavity, just over the right auricle. This opening led into a small chamber of limited extent, formed by pericardial adhesions. The finger could, however, be passed into the general pericardial cavity, showing that a complete sac had not been formed. Two ounces of pus in pericardium, and both pericardial surfaces coated with lymph. Endocardial membrane ca |