care and quiet are therefore required in such a case, and it is better to give digitalis than to bleeding very largely." (pp. 231, 32.)]

503. The symptoms of inflammation of the lungs and pleura, when they become severe, have great resemblance to those of extravasation. The circumstance distinguishing them is, that the symptoms of inflammation diminish after properly employing antiphlogistic treatment, whilst those of extravasation continue or increase.

504. Wounds of the Heart are fatal, either suddenly by the bleeding, or the danger depends on the contraction of its fibres, if only some of them be divided, on the collection of blood in the pericardium, and on the difficulty of cure from want of rest, and the consequent addition and extension of inflammation. Only slight wounds of the pericardium and of the heart are curable when the inflammation has not been great; at least distinct scars from previous injuries have been observed on the pericardium and on the surface of the heart (a). Cases, however, have occurred of wounds of the heart which have healed, in which several days after the injury and independent of it, death has taken place, and the bullet been found in the heart (b).

We presume that the heart is wounded from the direction and depth of the wound. The peculiar symptoms given of this injury are, a more or less severe pain in the region of the heart, extraordinary restlessness, and insupportable anguish; irregular intermitting pulse; cold extremities, cold sweat, and frequent faintings. The bleeding varies as the wound is superficial or deep; in both cases it may be absent on account of the peculiar contraction of the muscles, especially in oblique wounds. The blood either pours forth externally, or into the pericardium, or into the chest, with symptoms of extravasation and of internal bleeding. Special symptoms of wound of the pericardium and of the surface of the heart are not describable, and equally indistinguishable are the symptoms of the parts wounded. Perhaps the different colour of the blood in wound of the left and right side of the heart might render a diagnosis probable. The right ventricle is most frequently wounded. Wounds of the arteries are as dangerous as those of the ventricles; in them a small wound may be closed by contraction of the muscular fibres.

SPEYER (c) distinguishes the peculiar causes of death at these different periods in which it follows wounds of the heart; when death occurs early the cause is to be found in the heart itself, but in the more slow and subsequently occurring death the collection of blood in the brain and apoplexy are the cause.

[The following is an example of speedy death after wound of the heart (d). A man was jammed between two carts, taken up senseless, and dead by the time he had been brought to the hospital. On examination, the whole surface of the chest was found ecchymosed; the eighth and ninth ribs broken and depressed; the cavity of the left pleura contained a large quantity of dark-coloured liquid and grumous blood; the lung pushed upwards and inwards, and the diaphragm downwards. The pericardium was slit on its left side to the extent of two inches, and contained a small quantity of black coagulated blood. The heart presented at its hind surface a transverse wound corre sponding to that in the pericardium, an inch and a half long, and penetrating both vertricles, which had doubtless been caused by the broken ends of the eighth rib, which protruded into the cavity of the chest. The lung and diaphragm were ecchymosed, but not wounded. The left hypochondrion contained extravasated blood from a transverse lacerated wound of the spleen. The liver and all the abdominal viscera were both rather pale and bloodless. (p. 752.)

(a) RICHERAND, Nosographie Chirurgicale, vol. iv. p. 3.

217.

(b) Dict. des Sciences Médicales, vol. iv. P. PENADA, Saggi scientifici e litterari di Padova, 1794, vol. iii. part ii. p. 60.

(c) Ueber die Ursache der Todlichkeit eindrun gender Herzwunden; in the Heidelberger medi cinischen Annalen, vol. iv. part iii. p. 259.

(d) Case of Wound of the Heart by a Fragment of a Rib; in Lancet 1829-30, vol. ii.

In FEATHERSTONE's case (a) of the soldier who slipped, and falling upon his bayonet wounded the muscular substance of the left ventricle, lived only forty-nine hours, two quarts of blood were effused into the cavity of the chest, the pericardium was nearly filled with blood, and had a puncture which extended three-quarters of an inch into the muscular substance of the left ventricle about two inches from its apex. On opening the ventricle the bayonet was found to have penetrated its cavity, and to have cut through one of the fleshy columns of the mitral valve. A small coagulum was formed at the edge of the wound through the pericardium. Upon this case FEATHERSTONE observes that "death in this case, it is perfectly evident, was not produced from any alarm excited in the system by the wound, but occurred as a secondary consequence from the hæmorrhage increasing to such an extent as to interrupt the action of the heart and lungs. That the hæmorrhage proceeded chiefly from the heart must be admitted; there was no symptom whatever that indicated a wound of the lung; none could be found in the most deliberate examination; and the intercostal artery was entirely free from injury."

In Dr. BABINGTON's case (b), the marine who fell from the gangway on his bayonet, which pierced through the heart besides wounding other viscera, died in less than twenty-four hours. The emphysema which had commenced early at the upper part of the chest gradually augmented, and, about three hours before death, had reached the head and face, and before he died had extended over the whole body. The external wound was midway between the spine and white line, and the last rib and crest of the ileum; thence the bayonet had passed through the sigmoid flexure of the colon, through the stomach two inches from the pylorus; thence through the left lobe of the liver, through the centre of the tendon of the diaphragm and the pericardium; then through the heart near the tricuspid valve, through the lungs, and out of the right side of the chest, between the cartilages of the second and third ribs terminating in the substance of the pectoral muscle. In the belly there was a little bloody serum; in the pericardium a small quantity of blood, but in the right pleura two quarts of the latter fluid. In another case (c), where there was laceration of the pericardium, and a superficial wound of the heart, the patient who had been thrust against a wall by the shaft of a cart, lived twelve days. The sternum was fractured, and on examination its upper part was found protruding into the pericardium, and to have lacerated the right ventricle through nearly a third of its substance. There was not any fluid in the pericardium, but its inner surface was lined with false membrane. The heart itself pale, and its substance very friable. The right fourth, fifth and sixth ribs were fractured; a large quantity of blood extravasated in the pleural cavity on that side, and the lung pushed upwards. Sometimes extraneous bodies remain lodged in the heart, as in the following instances. HENNEN says he has "seen a preparation of a pin lodged in the human heart (but without any trace of how it got there.) The patient had complained of pain in his chest about three months previous to his death, and died of carditis. On examination, immense thickening and enlargement of the organ, with extensive effusion of coagulable lymph upon its surface, and adhesion to the pericardium was discovered." (p. 396.) FOURNIER mentions (d) the case of a soldier who received a gun-shot wound of the chest, and was taken up for dead, on account of the severe bleeding which had occurred. By great care the flow of blood began to diminish on the third day; his strength insensibly increased, suppuration came on, and many splinters of bone exfoliated. After three months the wound was healed; the patient's health restored, without other inconvenience than frequent palpitations of the heart, which harassed him for three years. During the following three years they became less troublesome, and he then died of disease unconnected with the heart. On examination the cicatrix was found very deep, with loss of substance of the fractured rib. The ball was found lodged in the right ventricle of the heart near its tip, enfolded in a great measure in the pericardium, and resting on the septum medium." (pp. 396, 97.)

PLOUCQUET also recites a case where a ball lodged in the anterior ventricle of the human heart, where it is said to have remained for years.]

Compare also DUPUYTREN, Leçons Orales de Clinique Chirurgicale, vol. ii. p. 157. LEES; in Dublin Journal. May, 1837.

STEIFFENSAND, Ueber Herzwunden und Blut Extravasat in der Brusthöhlt; in CASPAR'S Wochenshrift. 1838. No. 15.

DE JONG, Diss. de Vulneribus Cordis.

(a) Med. Chir. Trans., vol. ii.
(b) Medical Records and Researches.

Gröning, 1838.

(c) Répert Génér. de BRESCHEt.

(d) Cas Rare; in Dict. des Sciences Médicales.

JOBERT, Réflexions sur les Plaies Pénétrantes du Cœur ; in the Archives Générales de Médecine. Sept. 1839.

505. Only the most strict antiphlogistic treatment can in these wounds be employed. If extravasation into the pericardium take place, the making an aperture in it is the only although very doubtful remedy.

[505.* Wounds of the pericardium sometimes occur without injury of the heart, and may be fatal (1) or not (2).

(1) ASTLEY COOPER mentions a case in which a man was "wounded by another with a reaping-hook deeply through the cartilages of the ribs. The wound was small, but deep; and the man had the appearance of one who had sustained a dangerous injury. In two or three days after he had much pain in the region of the heart; a quick small pulse. In a few days more he began to swell, and could not lie down in bed. I forget how long he lived, but think for a fortnight or three weeks; and after his death, it was discovered that the hook had passed through the cartilages of the ribs into the pericardium, in which there was an effusion of bloody pus." (p. 232.)

(2) HENNEN relates a case of a bayonet wound of the pericardium and diaphragm. The patient recovered of the immediate effects of the injury, and died three months after of pneumonia. The aperture was large enough to admit the finger, and through it protruded a fatty pellicle or tongue fully an inch long and the fifth of an inch wide, convex and lobulated in front, but smooth and flat behind, and originating from the front of the heart an inch and a-half from its tip. A little above this the heart was connected to the pericardium by long, broad, and strong fibrous bands, evidently the result of inflammation long before his last illness. (pp. 397, 98.)]

506. Injuries of the Gullet, Thoracic Duct, Diaphragm, and Spinal Marrow, may be connected with penetrating wounds of the chest. As in these cases there must be always at the same time injury of the most highly important parts, the mortal result is usually not to be prevented. Wounds of the diaphragm, especially of its tendinous part, are always acccompanied with the most severe pain, anxiety, cramps, and convulsions, against which a strictly antiphlogistic treatment must be employed. If the wound in the diaphragm be large, the intestines of the belly may pass through the opening into the cavity of the chest.

Upon injuries of the spinal marrow, compare CASPAR in RUST's Magazin, vol. xiv. part iii. p. 409.

V. OF WOUNDS OF THE BELLY.

TRAVERS, BENJAMIN, An Inquiry into the Process of Nature in repairing Injuries of the Intestines; illustrating the Treatment of Penetrating Wounds and Strangulated Hernia. London, 1812.

8vo.

SCARPA, Sull' Ernie, Memorie Anatomico-Chirurgiche. Milan, 1809. fol.-The same translated. A Treatise on Hernia, with Notes, by J. H. WISHART. Edinb., 1814. 8vo.

FINGERHUTH, Dissert. de Vulnerum in Intestinis Sutura. Bonn, 1827.

JOBERT, A. J., Traité Théorique et Pratique des Maladies Chirurgicales du Canal Intestinal. Paris, 1829. vol. i. p. 52.

WEBER, H. L., De Curandis Intestinorum Vulneribus. Accedunt quædam Plagis Ventriculi atque Abdominis. Berol., 1830. 4to.

507. Wounds of the Belly (Vulnera Abdominis) are, 1, Superficial; 2, Simply Penetrating; 3, Penetrating, connected with injury of the Organs of Digestion, or of the Uropoietic System.

508. Superficial Wounds of the Belly. These are distinguished by some peculiar symptoms from the superficial wounds of other parts.

In injury of the tendinous sheaths of the abdominal muscles, especially from oblique stabs, severe inflammation, fever, pain, and vomiting quickly,

occur, and the inflammation often spreads considerably. Only strict antiphlogistic treatment and enlargement of the wound can remove these symptoms.

Bruises of the belly produce, by the concussion of the intestines, severe symptoms, as violent pain and tension of the belly, fever, often tearing of some intestine, extravasation into the cavity of the belly, and speedy death. Exudation of blood, or actual tearing of the vessels, may subsequently be produced, by gorging with blood of the vessels weakened by the shock. Here at first is indicated the most strict antiphlogistic treatment, often repeated bleedings, leeches, cold applications, cupping, and subsequently exciting remedies, infriction of volatile ointments, lotions of alcohol and caustic liquor ammonia, application of aromatic herbs, and the administration of arnica internally. In bruises of the belly the muscles are often torn, whilst the skin remains uninjured; in such cases, during the treatment, and after the consequent cure, pressure must be employed, to prevent the occurrence of rupture. The same caution is necessary in all wounds which penetrate the muscles; the patient must be put in such position as will entirely relax the abdominal coverings, and the union of the wound properly assisted by a broad belly-bandage.

If connected with the wound there be bleeding from the epigastric, internal mammary, or abdominal artery, it must be stanched, if possible, by ligature, for which purpose enlargement of the wound is requisite, or by

pressure.

[TRAVERS asserts that "where the integrity of the abdominal parietes is preserved, as in those which he has denominated simple wound, it is remarkable that effusion more generally follows. These are ruptures of the bowel, produced by falls or blows upon the belly, where the integuments are even unabraded.” (p. 36.)]

509. All wounds of the belly, even when superficial, must be treated antiphlogistically, because the inflammation easily spreads to the peritoneum If suppuration occur in the wound, the pus may collect in the cellular interstices of the muscles in their aponeurotic sheaths, or between the peritoneum and the abdominal muscles. Pain arises therefrom, and a more or less deep-seated swelling, with distinct or indistinct fluctuation. In such cases the wound must be either enlarged in the manner already described, or the pus must be discharged at the most prominent part of the swelling, by a proper opening, and the abscess treated according to the general rules. 510. Penetrating Wounds of the Belly. If wounds of the belly be not large and direct, the bowels or caul do not project, and neither fæces, bile, nor any stercoraceous gas escapes through the wound, it is difficult to determine whether they penetrate or not, for observation of the depth and direction in which the injuring instrument enters, so far as the introduction of a probe will show, is not always certain (1). The general symptoms also which usually accompany penetrating wounds of the belly, as small, weak, contracted pulse, pallid countenance, coldness of the extremities, great weakness, hiccough, vomiting, and swelling of the belly, are not always certain signs, as they occur also in sensitive, faint-hearted persons, in simple superficial wounds of the belly. In large penetrating wounds we are directed by the sight and touch.

[(1) The escape of the intestines from injury in penetrating wounds of the belly is very remarkable. HENNEN says he has "seen several; among others, he has been witness to the recovery of a soldier who had been shot through the abdomen by a ramrod, which passed in anteriorly, and actually stuck in one of the transverse processes of the vertebra, from which it was not disengaged without the application of some force. This

occurrence took place before Badajos in 1812." (p. 402.) The following, also, is a very striking example of the same kind, although fatal:

CASE.-H. D., aged fifty-two, was admitted under my colleague GREEN,

Oct. 8, 1829. Having fallen from a ladder, a height of twenty-six feet, upon some cast-iron railing, two spikes of which were broken by his fall; one was taken out of his body, but the other could not be found. There were two wounds in the belly, one just above the navel, and the other, out of which the spike had been taken, just above the left hip-bone. He had also a wound in the right arm behind the middle of the m. biceps flexor cubiti. He was much depressed, but after a time rallied a little. During the night he vomited, and next day, reaction having come on, he had pain and tenderness of the belly; but he soon failed again. Brandy was given, and leeches applied to the belly. No stool. On the third day the tenderness continued, and over the left ilio-pubie region there was a considerable inflammation, to relieve which leeches were again applied. In the afternoon he had a copious liquid motion, and in the evening several more very copious and offensive. At half past 11, P.M., he died. On examination, the omentum was found adherent to the wound; the intestines smeared with blood, and on raising them the cavity of the pelvis was seen full of blood; the broken spike, having passed without injuring any of the viscera, had torn the right common iliac vein, deeply indented the third lumbar vertebra, and lay across the rectum. No marks of peritoneal inflammation.]

511. This uncertainty is, in simple wounds, of no great consequence, and repeated examination with the probe is not needed, as very simple treatment is required. The opening is to be covered with sticking plaster, and a compress and belly bandage applied. In cut and torn wounds, the mode of their union depends on their extent and direction. Longitudinal and transverse wounds, if small, may always be united by the application of sticking plaster, compress, and a belly-band, or SIEBOLD'S bandage. In large transverse wounds, in which the intestines cannot be otherwise retained, stitching of the belly (gastroraphia) is necessary.

["Inquiries into the natural situation and extent of a wound of the abdomen," says TRAVERS," and the circumstances under which it was received, particularly the fulness or otherwise of the stomach, are chiefly important, as they enable the practitioner to study with effect, and follow up with advantage the operations of nature. It is almost needless to insist upon the impropriety of probing or dilating the wound, formerly a prevailing practice, and of applying adhesive straps and rollers round the belly, in place of warm emollient poultices and fomentations." (p. 74.)]

512. For union of wounds of the abdominal walls the twisted, interrupted and loop stitch are employed. The former effects the closest union, but the latter is suitable in all cases.

Stitching up the belly is always to be considered as an important matter; it easily causes a dangerous degree of inflammation, hiccough, vomiting, and so on. The dread of these occurrences and the numerous cases in which healing of the most severe wounds of the belly have taken place without stitching, must restrict its use. It must not, however, be overlooked that in some wounds of the belly, though not large, the union cannot be certainly effected without stitches, as in such cases the sticking plaster and bandages are easily displaced by the enlargement of the belly, which usually takes place by pressure, vomiting, and so on, and protrusion or squeezing of the bowel into the wound ensues.

513. The employment of the stitch differs according as the threads pe netrate the peritoneum, or only external to it, through the muscles and skin. In the latter case, as many sufficiently long and somewhat flattened threads are to be taken as stitches are required, furnished at one end with a pretty large curved and sharp-cutting needle. The edge of the wound is to be held between the fore finger of the left hand, introduced into the belly, and the thumb placed outside of it, and drawn somewhat towards the operator;