COLUMBIA LIBRARIES OFFSfTE HEALTH SCIENCES STANDARD HX00035696 v/Xv '////////// fiv5G Aig CalumlJia ^nitJem'tp intlifCitpotlfttigark Collese of $f)?fiiician£i anb ^urseonK Hibrarp THE SURGERY OF THE HEART AND LUNGS Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/surgeryofheartluOOrick Plate I. AXTERIOK \'II-:\V OF HiiART AND LuXGS OF DoG, IxjECTED IX Situ. (Page 484) THE SURGERY OF THE HEART AND LUNGS A HISTORY AND RESUME OF SURGICAL CONDITIONS FOUND THEREIN, AND EX- PERIMENTAL AND CLINICAL RESEARCH IN MAN AND LOWER ANIMALS, WITH REFERENCE TO PNEUMONOTOMY, PNEU- MONECTOMY AND BRONCHOTOMY, AND CARDIOTOMY AND CARDIORRHAPHY By Benjamin Merrill Ricketts, Ph.B., M.D. MEMBER AM. MED. ASSN.; WESTERN SURG. AND GYN. ASSN.; INT. MED. CONG., 1887; INT. ASSN. RAILWAY SURGEONS; MISS. VALLEY MED. ASSN.; CIN'TL ACAD. OF MED. ; OHIO STATE MED. SOC. ; AM. PROCTOLOGIC. SOC. ; HON. MEM. MED. SOC. STATE OF N. Y. ; HON. MEM. ST. LOUIS MED. SOC. ; FELLOW NEW YORK STATE MED. ASSN., AND MEM. SOCI^TE INTERNATIONALE DE CHIRURGIE ^^^S i ^p g ^ -3L- s THE GRAFTON PRESS NEW YORK MCMIV Copyright, 1 904, in the United States and Great Britain by THE GRAFTON PRESS 9^ I <^~ DEDICATION This Work is offered as a Token of Respect and Admiration to My Father Gerard Robinson Ricketts, M.D., and to the Surgeons who have had the Courage to Perform Surgical Operations of Any Character upon the Living Human Heart or Lungs PREFACE The author in his work as a surgeon has been brought in contact with several cases of pulmonary trouble requiring surgical intervention, and has thus become greatly interested in the subject. On taking up the study he found that there was no one work on surgery that gave more than a brief space to this subject. In order to obtain a knowledge of the operative surgery of the lung, or even a complete description of all the pulmonary lesions requiring surgical intervention, the stu- dent is forced to consult many works, and journals in many languages. For his own convenience the author collected a large mass of material, and compiled several bibliographies bearing on this subject. He also found that many questions regarding the tech- nique of lung surgery were in doubt. In order to settle these questions to his own satisfaction, he made a series of original experiments on dogs. Considering the paucity of information contained in the standard treatises, and the inaccessible sources of the most valuable matter, the author thought that a work of this char- acter might prove acceptable to students. Part of this work is an historical compilation, in an acces- sible form, of papers and reports scattered through the va- rious journals of this and other countries, together with a bibliography of the subject. For this part, no originality is claimed, but for the other Vlll PREFACE part, which details the author's experiments on dogs and the results obtained, he claims entire originality. No attempt has been made to write an exhaustive treatise on the surgery and surgical diseases of the lungs, but an ef- fort to consider all the diseases of the lung which may call for surgical intervention. Space has been devoted to each disease in proportion to its importance. This work is especially intended for practitioners and stu- dents. For this reason the descriptions of each disease, with its symptoms, diagnosis, and treatment, have been made as concise as possible; the aim being to enable the practi- tioner to recognize the various surgical diseases of the lung, in order that he may seek surgical assistance promptly when necessary. Each chapter has its own bibliography, so that those de- siring information on any particular subject need not con- sult a great mass of matter in which, perhaps, they have no interest. The reader must not think that all the works and reports mentioned have been read by the author; this would be a physical impossibility for a man actively engaged in his pro- fession. The most important, however, have been perused, every statement and reference has been verified and the authority for all statements has been given. This has been done in order that credit might be given where it is due, and also that the author of this work might not be held responsible for some other man's statement. It has been the author's aim to secure accuracy, but in a work of this character it is not always possible. An effort has been made to form a complete bibliography. The author, however, does not claim that it is exhaustive. The literature is so vast, and published in so many languages, that many papers and reports may have been overlooked by PREFACE IX the compilers of the various indices. Only those works and reports were inserted whose titles clearly indicated their sub- ject matter. Too many writers, unfortunately, choose obscure titles for their works. Then, too, some writings have not appeared in the kind of publications in which one would naturally ex- pect to find them. Some reports of interest are, perhaps, hidden away in the proceedings of societies, and cHnical reports of hospitals, and have never reached the ordinary channels of publicity. The second part the author considers the most important, because his experiments have cleared up certain questions of practical importance, and settled certain details of surgi- cal technique. All original experiments blaze the way for future work. It is the author's hope that this work may prove helpful to students, and that it may be the incentive for greater work on this subject. No effort was made to collect material from the classical or mediaeval writers, because such matter would be valuable only from an historical standpoint. It is the author's desire to pro- vide something that will be of immediate and practical benefit. The author wishes to commend the work and devotion of Dr. J. S. Wallingford and Dr. T. G. Sellew for their assist- ance in the experiments upon the lung. He also desires to express his appreciation of the devotion of his wife in correcting this manuscript. To W. H. Wamsley, Esq., he is very grateful for many of the excellent photomicrographs used in this work. He de- sires to commend the work and devotion of Miss Sadie B. Helbert in arranging the bibliography, and those of Miss Bertha Karl in handling the copy, and he further wishes thank- fully to acknowledge the many courtesies extended to him by Mr. Howard Ayres while the work was being conducted at the University of Cincinnati. CONTENTS PART I THE SURGERY OF THE HEART PAGE Preface vii Introduction 3 Terminology 5 CHAPTER I. Anatomy of the Heart 7 II. Experimental Research 31 III. Cardiamorphia 40 IV. Ectocardia 77 V. Gunshot, Lacerated, and Incised Wounds ... 91 VI. Cardioclasia 120 VII. Cardiorrhaphy — Cardiotomy— Heart Sutures . . 146 VIII. Cardiac Aneurysm 179 IX. Foreign Bodies 189 X. Cardioliths 192 XL Calcification 198 XII. Abscess 202 XIII. Syphilitic Gummata 206 XIV. Gangrene 212 XV. Benign Tumors — Fibromata, Lipomata, Angeiomata, Rhabdomyomata, Myxomata, Polyps 213 XVI. Malignant Tumors 223 XVII. Animal Parasites— Par.\sitic Fungi— Bacilli . . . 227 XVIII. Experimental Research on the Heart of the Dog . 247 Xll CONTENTS PART II THE SURGERY OF THE LUNGS PAGE Introduction 275 Terminology 279 CHAPTER I. Anatomy of the Lung 282 II. Abnormalities 289 III. Experimental Research (i 795-1903) — Influence op Trauma on the Lungs and Heart 295 IV. History of Ligatures and Sutures 300 V. Pneumonotomy — Pneumonectomy — Pneumonorrhaphy— Pneumonopexy — Bronchotomy — General and Local Anaesthesia 308 "Vl. Gunshot, Lacerated and Incised Wounds . . . 322 VII. Foreign Bodies 341 VIII. Abscess — Bronchiectasis 358 IX. Gangrene 375 X. Rupture 386 XL Hernla 390 XII. (Edema 397 XIII. Polypi in the Bronchia 402 XIV. Atelectasis Apneumotosis 405 XV. Syphilis . 411 XVI. Benign Tumors — Lymphoma, Chondroma, Osteoma, Dermoid Tumors 422 XVII. Malignant Tumors— Sarcoma, Carcinoma .... 426 XVIII. Anthrax 437 XIX. Parasitic Fungi— Actinomyces, Aspergillus, Pneu- monomyces, Oidium 442 XX. Animal Parasites: — Echinococcus, Paragonimus VVes- termani, Cysticercosis, Trichina Spiralis . . 449 Experimental Research on the Lungs of the Dog . 469 XXI. The Lung of the Dog 47^ Practical Hints and Theoretical Considerations, De- duced and Suggested by these Experiments . . . 474 Description of Plates 484 Record of Experiments 487 Analysis of Tables 40 LIST OF ILLUSTRATIONS PLATE I. Anterior view of heart and lung of dog injected in situ, Frontispiece Facing page II. Anterior view of heart 3 III. Injected section of heart muscle showing ramifications of capil- laries among the muscular fibres and how they appear to pass into them. Longitudinal section showing capillaries and muscular fibres . 10 IV. Longitudinal section of the cardiac muscular fibres and capil- laries. Longitudinal section, showing muscular fibres .... 18 V. Transverse section of cardiac muscular fibres, showing the capillaries and their ramifications. Transverse section of cardiac muscular fibres showing main blood-vessel and its ramifying capillaries .... 28 VI. Transverse section of cardiac muscular fibres and capillaries. Transverse section of cardiac muscular fibres .... 36 VII. Transverse section of heart, f inch from apex. Transverse section of heart, ih inches from apex ... 46 VIII. Transverse section of heart, 2J inches from apex. Transverse section of heart, 3 inches from apex ... 56 IX. Transverse section of heart, 45 inches from apex. Longitudinal section of heart dividing the right and left heart 66 X. View of right heart. Incision in right ventricular wall showing its thickness . . 74 XL Anterior view of left heart showing incision in apex. Penetrating incision of left ventricular wall showing its thick- ness 84 XII. Showing skewer penetrating the two ventricles from right to left. A direct penetrating knife wound of left ventricular wall . . 94 XIV LIST OF ILLUSTRATIONS PLATE XIII. XIV. XV. XVI. XVII. XVIII. XIX. XX. XXI. XXII. XXIII. XXIV. XXV. XXVI. XXVII. XXVIII. XXIX. XXX. XXXI. XXXII. XXXIII. XXXIV. XXXV. Facing page An oblique f)enetrating knife wound of left ventricular wall. A longitudinal penetrating wound of the heart showing how wounds of the heart may be extra-pericardial . 104 A non-penetrating transverse gun-shot wound of the left ventricular wall dividing the anterior coronary artery and vein 114 Section of heart muscle showing syphilitic lesion . .124 Fibromata 134 Fibroid. — Lipoma 142 Angeioma. — Myxomatous tissue 150 Myoma. — Rhabdomyoma 158 Polypus 166 Sarcomata, giant cell and spindle cell . . . .172 Sarcoma, small round cell 180 Carcinomata, epithelial and deep-seated .... 190 Cysticercus and eggs of Cysticercus 200 Cysticercus (bladder stage) 210 Trichina Spiralis, encysted in human voluntary muscle, and free 218 Oidium. — Actinomyces 228 Bacillus (Edematis Maligni. — Bacillus Typhoides . . 236 The cross represents the end of a kangaroo tendon which was used to ligate the left coronary artery and vein. (Experiment No. 3, page 263) The cross represents the end of a silk ligature about the anterior coronary vessels. (Experiment No. 6, page 264) 244 Showing silk sutures in place. (Experiments Nos. 9 and 10, page 266) 254 Showing silk sutures in place. (Experiment No. 11, page 266; No. 12, page 267) 262 Showing silk sutures in place. (Experiments No. 16, page 269; No. 18, page 270) 270 Anterior view of human lung 275 Normal human lung; anterior view showing apex of heart and tissues. — Posterior view . . . .278 Section of injected human lung, showing air cells. Section of normal human lung 282 LIST OF ILLUSTRATIONS XV PLATE XXXVI. XXXVII. XXXVIII. XXXIX. XL. XLI. XLII. XLIII. XLIV. XLV. XL VI. XL VII. XLVIII. XLIX. L. LI. LII. LIII. LIV. LV. LVI. LVII. LVIII. LIX. LX. LXI. Facing page Section of normal lung of a water dog (Necturus Later- alis) ... . •■ 286 Sections of a normal lung of a black snake . . . 290 Sections of normal lung of a bird (Martin) . . . 296 Sutures; Whipstitch, Herringbone stitch, Mattress, or quilted, stitch. Bell suture 300 Sutures; Combination of mattress and continued stitches. Tug stitch. Combined Tug and Tobacco Pouch stitch. Glover's suture Anthracosis in cancerous lung (Edema of lung — Polypus Lymphoma — Chondroma Osteoma — Dermoid cyst . Sarcomata, small round cell and small spindle cell . Sarcoma, giant cell. — Carcinoma, epithelial . Bacillus Anthracis (spores). — Bacillus Aerogenes Cap sulatus Bacillus Friedlander (acute croupous pneumonia). Pneumonia (human lung) Diplococcus (Fraenkel). — Bacillus Tuberculosis Actinomyces. — Aspergillus, in lung of cow . Aspergillus Fumagatus. Mycelium of Aspergillus Pneumonomycosis Echinococcus. — Echincoccus, advanced stage Echinococcus. — Paragonimus Westermani Paragonimus Westermani (from lungs of a hog), i. Sec- tion containing a lung fluke cyst cut open. 2. Lung flukes, natural size. 3. Contents of cyst containing eggs of lung fluke, greatly magnified .... Lungs of a hog showing cysts caused by lung flukes Posterior view of heart and lungs of a dog injected in situ. (Description, page 484) Transverse section of the lower lobes. (Description, page 484) Transverse section of the heart and lungs. (Description, page 485) Posterior view of transverse section of the heart and lungs. (Description, page 485) Transverse section of the heart and lungs. (Description, page 485) . . . . , 304 310 314 318 324 328 332 338 342 348 354 360 364 370 376 380 386 388 394 398 402 408 XVI LIST OF ILLUSTRATIONS PLATE LXIL LXIII. LXIV. LXV. LXVI. LXVII. LXVin. LXIX. LXX. LXXI. LXXIL LXXIIL LXXIV. LXXV. LXXVI. LXXVII. LXXVIIL LXXIX. LXXX. LXXXI. Lxxxn. LXXXIII. LXXXIV. LXXXV. LXXXVL LXXXVII. Facing page Transverse section of the lungs. (Description, page 486) 412 Posterior view of transverse section of the lungs. (De scription, page 486) Experiment No. 4, page 487 Experiment No. 6, page 488 Experiment No. 7, page 488 Experiment No. 8, page 488 Experiment No. 10, page 489 Experiment No. 11, page 489 Experiment No. 13, page 489 Experiment No. 14, page 489 Experiment No. 16, page 490 Experiment No. 18, page 490 Experiment No. 19, page 490 Experiment No. 20, page 491 Experiment No. 21, page 491 Experiment No. 22, page 491 Experiment No. 24, page 491 Experiment No. 25, page 491 (Pneumonopexy) Experiment No. 26, page 491 Experiment No. 27, page 492 Experiment No. 28, page 492 Experiment No. 30, page 492 Experiment No. 31, page 492 Experiment No. ^^, page 492 Experiment No. 34, page 492 Experiment No. 46, page 492 416 420 424 428 430 434 438 440 444 448 45° 452 456 458 462 466 472 474 478 482 486 488 490 492 494 PART I THE SURGERY OF THE HEART Plate II. Right common carotid a Right in1 Right subcia Right vertel Right subcia Right inno Right interna Superior Vena azygos Right pulm R. pulmonary nferior thyroid veins Right auri Right auricul Pulmonary artery Left auricular appendix Anth:rior \'iew of the Hkart (From Deaver's "Surgical Anatomy.") PART I THE SURGERY OF THE HEART INTRODUCTION Injuries and diseases of the heart have resisted surgery longer than almost any of the tissues or organs of the human body. They, however, no longer offer such resistance, but find themselves subject to attack on the same surgical prin- ciples as other parts of the body. The recovery of twenty cases out of fifty-six penetrating wounds of the human heart, after having been closed by suture, is significant, and this, too, all having been done since 1895. The object, therefore, of this work is more fully to demonstrate by the cases operated upon, a general resume of injuries, pathological conditions, and experimentation, that it should no longer be exempt from surgical measures. The chapter on anatomy refers to both the human and comparative features to a limited degree, and of necessity calls for a consideration of abnormalities, such as malposi- tions, displacements, and malformations, each of which has a separate chapter. The frequency of abnormalities is be- coming generally known, and their importance in cases re- quiring surgical intervention better appreciated. Experi- mental research bearing directly upon the surgical aspect has been exceedingly limited as compared with that of phys- iologic or anatomic research. Wounds of various kinds are included in a separate chap- ter, that the character of wounds most amenable to surgery 3 4 THE SURGERY OF THE HEART might, if possible, be determined. Aneurysm, foreign bodies, ossification and calcification, together with abscess, syphilis, and gangrene, possess features which will have a great bear- ing upon and will influence the future surgical work on the heart. The application of surgical principles in certain cases of aneurysm of the heart will, no doubt, be accomplished by suture, electrolysis, or the injection of gelatine or something of a similar character. The removal of a certain class of foreign bodies, whether they have formed within or have entered from without, should and no doubt will, be accomplished. That a cardiac abscess should be incised and drained there can be no doubt. In a selected number of cases the application of carbolic acid counteracted with alcohol after an abscess of the heart has been incised, might possibly permit of closing the walls of the abscess with suture. The same principles might be suc- cessfully applied to cases of gangrene of the heart. Tumors of a pedunculated variety, on the external sur- face, should be removed, even when pedunculated within the cardiac chambers, their removal is about as possible and rational as the removal of foreign bodies from the chambers of the heart. Parasitic cysts (animal or vegetable) when upon the ex- ternal surface, or in the wall of the heart, should be incised and drained. TERMINOLOGY Acardia absence Acardiohaemia lack of blood Acardiotrophia atrophy Aerendocardia presence of air in the heart Angeiocardiokinetic agents stimulating vessels of heart Angeiocarditis inflammation of heart and blood-vessels Atelocardia poor development Cardiac cycle a complete movement Cardiagra gouty attack Cardialgia pain Cardianastrophe displaced to right Cardianeuria lack of nerve stimulus Cardiant. affecting the heart Cardiarctia stenosis Cardiasthma dyspnoea Cardiatelia poor development Cardiatrophia 1 t h Cardiatrophy j ^ ^ Cardiauxe enlarged Cardiectasis. ; dilatation Cardielcosis ulceration Cardiemphraxia obstruction of current Cardiocele hernia Cardiocentesis aspiration Cardioclsesia rupture Cardiocrystallus heart crystal Cardiodemia fatty degeneration Cardiography description Cardiohaemothrombus. . . heart clot Cardiokinetic exciting the heart Cardiolith concretion in the heart Cardiology anatomy, physiology and pathology Cardiomalacia softening Cardiomegalia enlargement 5. 6 THE SURGERY OF THE HEART Cardiomorphia malformed Cardiopalmus palpitation Cardiopathy disease Cardiopericarditis inflammation of heart and pericardium Cardioplegia paralysis Cardioptosis downward displacement Cardiorrhexis rupture Cardiosclerosis hard Cardiostenosis constriction Cardiotomy dissection Cardiotoxis poison Cardiotrauma injury Cardiovascular pertaining to blood-vessels Carditis inflammation Carditopography topographical anatomy Dexicardia "| Dexiocardia V to right Dextrocardia j Ectocardia 1 abnormality of position Ectopia cordis j Hajmatolysis imperfect coagulate Hccmatomyces fungus Hajmatopericardium blood in pericardium Haematophyte vegetable organism Haematoxin blood poison Ha^matozoon animal organism Ha^mocardiorrhagia haemorrhage of heart Hemicardia one auricle; one ventricle Monocardium a single chambered heart, or one not completely divided Mycosis pathological mycosis Orthodiagraphy X-ray picture of the heart CHAPTER I ANATOMY OF THE HEART (HUMAN AND COMPARATIVE) The embryonic heart of the lower vertebrates differs both in form and origin from the heart of the higher verte- brates. In some of the lower vertebrates the heart never develops much beyond the embryonic stage. This form per- sists throughout life. Anomalies of the human heart are very often only cases of arrested development of the embry- onic heart. This arrest may occur at any stage, hence anomalies of the human heart may show any of the embryonic forms. The heart is the first permanent organ of the embryo to take up its functional activity. In its earliest forms it pre- sents the characteristics of the central impelHng tube of the invertebrates, which is functionally analogous to the heart of the vertebrates. This impelling tube of the invertebrates is a very simple mechanism to perform its office. The arteries empty into the anterior, and the veins into the posterior ex- tremity. One school of evolutionists points to the development of the mammahan heart as proof of their dictum, that the em- bryo of the vertebrates presents at various stages of its de- velopment the characteristics of the adult heart of all the lower forms. At first the heart of the human embryo is exactly similar to the invertebrate heart described above. Then it takes the form typical of that of the fish, i.e., an organ of three cavities, a simple auricle, a simple ventricle, and a bulbus 7 8 THE SURGERY OF THE HEART arteriosus at the origin of the aorta. The subdivision of the aorta into four or five arches resembles the entrances of the gill-cavities of the cartilaginous fish. This form of circulat- ing apparatus is common to all vertebrates, at least in the earliest stage of their development. This is the permanent form in fish, although in some there is further development of the vascular system. Irr the higher vertebrates the plan of circulation is totally changed, because of the formation of new cavities in the heart and the formation of new vessels. Hence it is not strictly correct to speak of the vascular arches in their necks as branchial arches, since no branchiae, or gills, are ever devel- oped. The highest pair of the so-called branchial arches, by union of the aortic trunk, help to form the subclavian and carotid arteries, the middle pair undergo the greatest change, the right becomes obliterated and the other becomes the " arch of the aorta." Many of the anomalies of arteries and veins can also be explained as arrested development in the embryonic state. In birds and the lower mammals there are two venae cavae superiores. At the birth of the human foetus there is a change in the plan of circulation on account of the cessation of placen- tal circulation. With the first breath of the new-born an im- mense quantity of blood is transmitted to the lungs. In a short time the ductus venosus and ductus arteriosus shrivel up and become mere ligaments; at this time the foramen ovale becomes closed by its valve. The circulation, which had been reptilian in character, now becomes of the perma- nent form found in birds and mammals. The heart of the dugong is so deeply cleft from apex to base as to seem two separate organs. The same condition is found in the human foetal heart at a very early period. In man the vena porta is analogous to the aorta of the fish. This shows that it is properly regarded as arterial in character. It bears the same relation to the general circula- ANATOMY OF THE HEART 9 tion in man that the respiratory circulation in the Mollusca and Crustacea does to the general circulation of these orders. The mammalian heart may be described as an organ whose functions are those of a pumping-engine to propel blood through the body. The human heart is an oval or pear-shaped organ, three to five inches wide and three to four inches thick, weighing nine to seventy-two ounces, rarely above twenty-five ounces, normally nine to twelve ounces in the male and seven to ten ounces in the female. The broadest part of the heart, called the base, is directed upward and backward and to the right, extending from the level of the fifth dorsal vertebra to the eighth, (Heath says from the sixth to the ninth.) The apex, or pointed end, of the heart can be felt between the fifth and sixth ribs, a little below the inner side of the left nipple. (Ouain says three and one-quarter inches from the middle line of the sternum and one and one-half inches below the nipple.) The margins of the lungs cover all but a small part of the heart. This part of the heart left uncovered is part of the right ventricle, is irregular in outline and about two inches square in area. The heart has four cavities, the right and left auricles in the base, and the right and left ven- tricles toward the apex. It may be considered as a double heart, keeping in mind the typical heart of two cavities found in the lower orders. Like the lungs, and other important organs, the heart has a separate individual envelope known as the pericardium. Normally the pericardium conforms to the general shape of the heart reversed. It is pyriform in outline with the small end uppermost ; the base rests upon the diaphragm. It is con- tinued above to cover the great vessels of the heart, and connects with the deep cervical fascia at a height of two inches above the origin of these vessels. The four cavities of the heart approximate one another in lO THE SURGERY OF THE HEART size. The contents of each cavity are about three ounces. The auricles will hold a fraction less. The walls of the left ventricle are much thicker than those of the right. This is undoubtedly in compensation for the greater work that it has to perform. It has been found experimentally that the left ventricle contracts with more than double the force of the right. The walls of the left ventricle are nearly three times as thick as those of the right. All this is in agreement with the laws of mechanics, since the left ventricle has far greater arterial resistance to overcome. In regard to the capacity of the cavities, it has been noted that the ventricles receive more blood from the auricles than the latter could transmit by simply emptying themselves once. If three ounces be taken as the capacity of the ventri- cle, and eighteen pounds the weight of the blood in the body of an average sized man, it will require ninety-six strokes to force the whole amount of blood through either side. If seventy-two pulsations per minute be taken as the average, it will require one and one-third minutes for a given particle to return to a given point, that is, if it was not sent else- where. It is not only interesting, but of great practical impor- tance, to consider the mechanism of the heart and circula- tion in the various orders of vertebrates, for by such study a more thorough understanding of the human cardiac and circulatory apparatus can be obtained. This comparative study also throws light upon some of the seemingly inex- plicable human anomalies. Comparative Anatomy The ventricles of the heart are but imperfectly divided in the class Reptilia, except the crocodil- ian group, in which they are completely divided. In some of the Chelonians the communication between the auricles is permanent. The fossa ovalis, which represents the primi- tive division of the heart, is more completely obliterated in Plate III. X 100. Injected Section of Heart Muscle Showing Rami- fications OF Capillaries Among the Muscular Fibres and How They Appear to Pass Into Them. (Dr. A. V. Meigs.) X 300. Longitudinal Section Showing Capillaries Muscular Fibres. (Dr. A. Y. Meig-s.) AND (Anatomy of the Heart.) ANATOMY OF THE HEART II the kangaroo than in man. In those Batrachians which have but a single ventricle the root of the aorta is dilated into a bulbous aorta or biilbus arteriosus. The latter is rhythmically contractile in the Elasmobranchii, but not in the Teleosteans. Where the heart consists of but two cavities, one auricle and one ventricle, as in fishes, the root of the aorta is dilated into a bulbus arteriosus, and the venous channels terminate at the heart in a sinus venosus. The heart of the lancelet consists of but a single tube. The cavity of the pericardium is continuous with that of the peritonaeum in the Myxinoid fishes and Elasmobranchii. The crocodiHan heart gives rise not only to the pulmonary artery, but also to the aortic arch. In frogs and most of the reptiles a special arrangement of valves is provided for the propul- sion of the venous blood into the pulmonary arteries, and the arterial blood, for the most part, into the aortic arches. These groups have pulmonary arteries coexisting with a sin- gle or an imperfectly divided ventricle. The apex of the heart of the dugong is deeply notched; this fact can be detected externally. The heart of birds is more elongated than the human heart, while that of the Chelonian is shorter and broader. In Amphioxus, the simple vesicular heart is con- tinued forwards preaxially, into a median artery, whence on each side diverge very many pairs of arteries. The same condition is found amongst the vertebrates in the lancelet. In no other member of that sub-kingdom can aortic arches by any calculation, or at any period of life, be found to ex- ceed eleven on each side. (St. George Mivart, "Elementary Anatomy.") Amongst sharks the genus Heptanchus have probably seven distinct branchial arches on each side. In the Lepido- sirens and Ceratodus there are five branchial arches on each side; the perch has but four. In the frog, at that period of its tadpole stage when the gills begin to atrophy, three branch- ial arteries coexist with the three corresponding vessels going 12 THE SURGERY OF THE HEART to the dorsal aorta. At this time there is direct communi- cation between neighboring arteries and veins, although each artery and vein minutely divides in the gill beyond the points of communication. In the adult frog there is no breaking up of the aortic arches by any interposed ramifications. At an early age of his existence man possesses a ductus arteriosus connecting the pulmonary artery with the aorta. In Cryptobranchus this connection is permanent and on both sides of the body. The crocodile has two aortic arches, each ventricle giv- ing off one. The two common carotids and the right sub- clavian originate in one trunk in the Hon. The hedgehog has two innominate arteries. The two common carotids in birds ascend in close juxtaposition. One of these is sometimes much reduced in size, or even aborted. The vertebral artery in the llamas perforates the neural laminae instead of pass- ing through the cervical transverse processes. Birds have a primitively double aortic arch springing from the left ven- tricle, but only the right half develops into the permanent form. It is the left half of this primitively double arch which is developed in mammals. The great arteries which supply the head and forelegs originate in common from the aorta as one great trunk. But in the dugong all the great arteries which supply the head, et caetera, have each a separate origin arising from the aorta. In the domestic ox, the internal carotid breaks up inside of the skull into a network of small arteries, I'ctc niirabilc. There are differences in the proportions existing between the external and internal carotids, and also variations in the course taken by each which characterize different groups of mammals. In the sloths and slow lemurs, the branchial artery breaks up into a number of branches running side by side. The femoral arteries in the same animals and also among the Echidna are similarly divided. In some of the Cetacea (por- poise), the intercostal arteries form great convoluted rctia ANATOMY OF THE HEART I3 viirabilia. In the osseous fishes and in the Lepidosiren, a small rete mirahile is developed from the first, or hyoidean, aortic arch. In many fishes there is a less number of inter- costal arteries than intercostal spaces : in this class of animals the arter}- of the pectoral limb is given oft from the dorsal aorta immediately after its formation. The dorsal arten,- dilates beneath each vertebral centrum of the abdomen in the carp. In fishes this artery gives off many small branches to the kidneys. The internal iliac arteries do not share with the external in a common origin. The middle sacral arten.- continues much farther and is of larger size in the kangaroo than in other vertebrates, the internal iliacs are larger than the ex- ternal and the inferior mesenteric artery is aborted. A rctc mirahile is formed in the Porbeagle shark by the ramifications of the cceliac arteries. In one point there is a great difference between arteries and veins. Excluding rdia mirahilia and all gill structures, it will be found that the arteries never, after dividing, reunite to form second aggregations. But the veins do break up and reunite to form, so as to speak, a new system. The so- called portal circulation is thus formed. The portal veins break up into a minute network in the liver, and then gradu- ally reunite to form the hepatic veins which carry the blood to the heart. The venous rctc mirahile attains its maximum in the ab- dominal region of the porpoise. The two azygos are equal. or nearly so in the monotremes. Rabbits have two superior vencB cavcB. Each of these opens into the right auricle by a separate and distinct aperture. The middle sacral vein is greatly increased in size and. of course, in importance in the Cetacea. all of this class having a ver\- large coccygeal region. The veins of the caudal region and the pelvic limbs enter the kidney in the Batrachians and there form a network. These ramifications reunite on emerging from the kidney to 14 THE SURGERY OF THE HEART form a new trunk to carry the blood to the heart. Thus in this class there is a tertiary distribution of blood in the kidney, similar to the secondary or portal circulation in man. The abdominal veins, however, go directly to the liver and do not help to form this renal circulation. The abdominal veins of birds go directly to the vena cava inferior. In most Batra- chians and reptiles the great veins dilate into a rhythmically contractile siuiis vcnosus. The permanent venous system of fish is exactly repro- duced in the human embryo. Fish have two cardinal veins uniting to form a ductus Ciivieri which empties into a sinus vcnosus at the heart. The veins themselves are contractile in certain groups. The portal vein of Thyxine contracts rhyth- mically; the eel possesses a pair of small contractile vesicles on its caudal vein ; in the limbs of many Batrachians the root veins are contractile; the veins which traverse the membranes of the wings of bats are similarly contractile; and Amphioxus is sui generis in this regard, as in many other points. Not only is the portal vein contractile, but many veins of lesser im- portance also possess this property. The veins of the Cetacea have no valves. In fish and young batrachians, the blood is not propelled in a double circuit as in man, but makes a single great cir- cuit, only returning to the heart when the whole round has been completed. In this case only venous unaerated blood is propelled by the heart. The blood leaves the heart by the bulbous aorta, passes to the gills, where it is aerated. This aeration is accomplished by the reception of oxygen from the particles of air mechanically mixed up with the water in which the animals Hve. All air-breathing vertebrates like man possess two circu- lations; that is, part of the blood returns to the heart, before being distributed to the body generally; but both venous and arterial blood are more or less mixed up in the heart itself in all batrachians, and in such cases the aortic arches propel ANATOMY OF THE HEART 1 5 an impure fluid. The arrangement, structure, and mechanism of both the chambers of the heart and aorta are so complex that the mixture of the venous and arterial blood is incom- plete. Nearly all the blood from the lungs is forced into the aortic arch, which supplies the anterior portion of the body. This process is found also in some still lower orders, as in the common frog. Although the two states of the blood are strictly divided between the two sides of the heart in crocodiles, yet the blood in the circulation is impure. This is because of the communi- cation between the two aortic arches after leaving the heart. In the perch, the blood carried to the gills can enter the dorsal aorta only by means of the capillaries of the gills. There is a complete continuity of each arch from the heart to the dorsal aorta in the embryo of the fish. In the Lepidosiren and Monopterus this condition persists throughout Hfe. Certain lesions of the heart cannot be diagnosticated un- til constitutional disturbances are produced. But the same lesion, even in the same person, need not produce the same constitutional disturbances. It is essential in all heart lesions which might be benefited by surgical treatment, that the cause be discovered early. The patient who undergoes any cardiac surgical operation requires all the strength, vitality and resistance possible successfully to withstand the shock. The same may be said of operations on any of the internal viscera. Because of the lack of knowledge of the pathologi- cal physiology of the viscera, and especially because of the uncertainty surrounding the pathological physiology of the heart, this and correlated subjects are taken up much more fully than is usual in a work of this character. The pericardium consists of two layers, a fibrous and a serous layer. The fibrous layer is a dense membrane which is attached to the diaphragm. Eight tubular sheaths are formed from the superior portion of the pericardial sac for the great vessels at the base of the heart. The serous layer is l6 THE SURGERY OF THE HEART formed into a closed sac. The muscular tissue of the heart is similar to the ordinary striped or voluntary muscle. There are both longitudinal and transverse striations. Each individual fibre consists of a number of muscular elements. The latter consists of a nucleus, and a film which presents the appearance of granular protoplasm. This nucleus, in which is found an intranuclear plexus, together with the thin film, constitute what Max Schultze calls the muscle corpuscle. Each of these so-called muscle corpuscles is surrounded by a mass of that material which seems to be the functionally active part of the heart substance. The ends of each individual muscle element, which are serrated or bifurcated, dovetail into a sim- ilarly formed end of another element. These elements are cylindrical in shape. Each fibre is made up of several of these muscle elements united, and because these elements do not always unite end to end, but laterally and otherwise, thus there is produced the reticulated appearance of a sec- tion of the heart. In elderly persons a golden yellow or brown pigment is sometimes found at the poles of the nuclei of the muscle corpuscles. The interstices of muscular network are filled by a highly vascular connective tissue, which is in direct contact with the muscular elements. If the human heart be removed very soon after death, the inner surface of the endocardium will be seen to con- sist of a single layer formed of nucleated endothelial cells, flattened. Beneath this endothelial layer there is a reticu- lated stratum, also formed of flattened cells, which, how- ever, are branched. Trabecul^e run from this layer into the connective tissue found between the muscle fibres. In the substance of this network of cells, are minute muscular bands analogous to those in the myocardium. A stratum of elastic tissue lies beneath this layer of network disposed cells. Numerous arteries and veins are found on the surface of the heart. All of these vessels are of ordinary structure. ANATOMY OF THE HEART I7 Within the walls of the heart, only the veins of large size have three coats. The walls of the smaller veins are composed of a single layer only of endothelium. In other words, the smaller veins running through the heart's walls are identical in structure with the capillaries. The structural composition of the walls of the arteries within the substance of the heart is normal, i.e., three coats. There is one peculiarity characteristic of the cardiac arteries. This refers to the way in which the arterioles become merged into capillaries. The number of efferent capillaries is greater than the number of afferent. The capillaries run in all direc- tions among the muscular fibres. As A. V. Meigs says: " The capillaries not only enter the muscular fibres, but also actually penetrate to their very centres." (" Origin of Dis- ease," Philadelphia, 1899; p. 65.) " The superior, middle, and inferior cervical ganglia form the cerebro-spinal nerves of the heart." The above mentioned ganglia are of the sympathetic and form no part of the cerebro- spinal system. From them we have the superior, middle, and inferior sympathetic cardiac nerves given off. These enter the thoracic cavity, and uniting with branches of the pneumo- gastric, form the cardiac plexus. Therefore, the pneumogas- tric is the cerebro-spinal nerve, and the cardiac branches from the superior, middle, and inferior cervical ganglia are sym- pathetic. From the plexus thus formed by the pneumogastric and sympathetic, cardiac branches are distributed to the heart." W. E. Lewis. The structure of the veins within the walls of the heart proves that nature has made abundant provision for its nourishment. The veins, very probably, participate largely in the nutrition of the cardiac tissues and furnish the means of transportation of waste material ; because of their distensi- bility they may act the role of reservoirs. These peculiarities in structure of the heart have an im- l8 THE SURGERY OF THE HEART portant bearing in the production of the cardiac movements. It is only in the light of these peculiarities that the mechan- ics of the heart-beat becomes comprehensible. An intimate acquaintance with the nervous mechanism of the heart is of even greater importance. Branches from the superior cervi- cal ganglion, middle cervical ganglion, and of the inferior cervical ganglion form the cerebro-spinal nerves of the heart. The glosso-pharyngeal, pneumogastric, hypoglossal, and the first cervical nerves also originate in the superior cervical ganglion. The cardiac cerebro-spinal nerve originates in the middle cervical ganglion, and is placed in communica- tion with the fifth and sixth cervical nerves at its origin. These connections must be kept in mind in order to demon- strate how and why the heart is influenced so profoundly by lesions of other organs and tissues. Peripheral branches of the above mentioned cervical ganglia, and sometimes also a branch from the first thoracic nerve, by their union with the cardiac branches of the pneu- mogastric, form the intricate plexus cardiaciis around the base of the heart, under the arch of the aorta. Usually these branches divide into two portions: The superficial portions lie in front of the aorta, and the deeper portions lie behind and below the aorta. The latter portions are the largest. The walls of the heart are pierced by filaments from the plexus cardiacus. On the nerves as they ramify through the heart are many microscopic ganglia. Wrisberg's ganglion in the centre of the plexus cardiacus plays the most important part of these ganglia. In some of the lower orders these ganglia have been proven to perform the special function of regulating and controlling the functions of the heart. In these orders, they have the power to insure the continuance of the heart-beat, even after the connection between the h^art and the central nervous system of these animals has been severed. The pneumogastrics or vagi are the most important Plate IV. X 100. Longitudinal Section of Cardiac ^Muscular Fibres AND Capillaries. (Dr. A. V. IMeigs.) X 100. Longitudinal Section Showing Muscular Fibres. (Dr. A. V. Meigs.) (Anatomy of the Heart.) ANATOMY OF THE HEART 1 9 nerves in the body. They are the only cranial nerves abso- lutely essential to life. If both vagi be severed, death will follow in a few hours. The connection between the pneu- mogastric and the sympathetic system is exceedingly inti- mate. In some of the lower orders of the animal kingdom it performs the functions of the sympathetic, and in others it takes the place of the sympathetic. It is what may be termed a double-acting nerve, since it possesses both motor and sensory activities. These impulses are transmitted to the heart by separate systems of nerve fibres; centrifugal impulses which slow the heart-beat over one set of fibres, and over the other centripetal impulses pass which influence the heart's movements by reflex action. The pneumogas- trics are closely connected with many nerves of the cerebro- spinal system. They anastomose -immediately after their exit with the neighboring nerves, and pneumogastrics and sympathetic unite with both the hypoglossal and glosso- pharyngeal nerves. The vagus has a recurrent branch which goes to the dura mater. Some scientists hold that the hypoglossal is simply a coalescence of the anterior roots of the vagus. In some of the mammalia and in embryos it has a posterior root and a ganglion of its own. It is believed by many comparative anatomists that the hypoglossal is formed by the coalescence of certain spinal nerves, three in number, found in certain of the lower orders of animals, but not found in man, in any stage of existence. Many experimenters have attempted to discover the exact function of the vagus, at least in regard to the cardiac movements, but there is still much uncertainty surround- ing the subject. A nerve centre, situated in the floor of the fourth ventricle, produces normally similar effects to those caused by irritating the vagus. The cardiac ganglia previously mentioned are not only found deep within the cardiac tissues, but are numerously 20 THE SURGERY OF THE HEART scattered over the walls of the heart just beneath the ex- ternal surface. It is claimed that the injury of any one of these ganglia results in instant death. This explains the cause of the almost instantaneous deaths in many cases of cardiac wounds. It also shows why cardiac surgery must be always a formidable undertaking. There is another cause for caution in suturing or incis- ing the heart in that the external cardiac blood-vessels are so highly elevated above the surface of the heart. The coro- nary arteries are raised to a relatively great height above the exterior surface of the heart. Each artery is accompanied by the corresponding vein. These blood-vessels branch in almost regular order, and the branches are thrown off at almost right angles to the main vessels. Whenever an artery branches, the accompanying vein also does the same, but there is a slight distance between the places of division. The intra-cardiac ganglia proper are never macroscopic in size. They are made up of scattered unipolar cells, but a few may be bipolar. The connection between each ganglion and the other ganglia is very intricate; so is the connection with the external cardiac nerves. The most powerful of the intra-cardiac ganglia proper lies in the auricular saeptum. The paralysis of this ganglion by opium will cause a reversion of the cardiac contraction; and the motion will be from the ventricles to the auricles, instead of the normal contraction from the auricles to the ventricles. The other important ganglia are Remak's in the wall of the sinus venosus, at the point of union with the auricles; Bidder's near the junction of auricles and ventri- cles, and the one in the auricular sseptum. There are no ganglia in the ventricular sn[?ptum or apex. Mechanics of the Heart-Beat. — Although much work has been done to clear up the mystery surrounding the cardiac movements Ziemssen says, " The heart moves upward and to the right during contraction;" while Senac claims that it is ANATOMY OF THE HEART 21 depressed forward and downward. Perhaps it would be well at this time to recall the fact that there is no anatomical con- nection of the muscular fibres of the ventricles with those of the auricles, therefore influences which affect the one need have no effect on the other. The cardiac movements, in fact, are found to be in ac- cord with the theory. The two auricles contract simultane- ously; before this action ceases and about one-tenth of a second after it begins, the two ventricles contract in unison. The ventricular contraction never varies, no matter how rapid or how slow the heart-beat as a whole may be. A fourteenth of a second is consumed for the contraction of the ventricles. (Kirke, " Text Book of Physiology.") There are exceptions to the generalizations concerning the heart. A case was reported by von Ziemssen and Ter Gregorianz of a woman who was badly injured in an acci- dent. They made several observations on the heart-beat, and found that the auricles kept contracting after the ven- tricular systole had commenced. The impulse-beat may be best detected in the left fifth intercostal space. The rhythm of the heart-beat and the extraordinary vitality of the heart are full of interest and of great practical importance. There is nothing unusual about the contraction of the cardiac muscles, it is simply analogous to that of the unstriped muscles. The movement of the heart, as a whole, during the heart-beat, has been happily described as a peristaltic contraction. This power of contraction of the heart-beat seems to be a force or power that is inherent in the substance of the heart. Even before the embryonic heart is differentiated from other structures, that is, when the heart consists of only ordinary cells, before it has any nervous mechanism, even before the formation of a nervous system in the body at large, there are cardiac contractions. The inherent force or power which seems to impel the 22 THE SURGERY OF THE HEART cardiac substance to contract is well illustrated in the com- mon frog. A frog's heart, and that of a tortoise, have been known to beat several hours, and in some cases even days after removal. When the beats become infrequent, which they will sooner or later, an additional one can be induced by stimu- lating the heart with a blunt needle. The latent period (time interval between application of stimulus and resultant), how- ever, is much increased. See says: " Ligation of one coronary artery in a dog, in two minutes caused the regular cardiac contractions to give place to fibrillar twitchings, and that ventricle is first chiefly affected whose coronary artery has been ligated." (See Chapter on Results of Experiments.) The auricles can be made to pulsate independently of the ventricles, and at a different rate, by a transverse in- cision through the junction of the auricles with the ven- tricles. The rhythm of the cardiac movements in a heart wholly excised differs from that of an unremoved heart. The rhythm in an excised heart is in order, auricles, ventricles, sinus venosiis and bnlhiis arteriosus. The heart has been re- moved in some experiments at the junction of the sinus venosus and auricles, and in such cases it was found that while the remaining portion of the heart continued to beat as usual, the excised portion remained motionless for a varia- ble period, and when movement was resumed, the rhythm differed from the unexcised portion. If only a ventricle be removed, the period of quiescence will be longer than in the above experiment. The rhythm also of the excised portion will differ from that of the unre- moved portion. Division of the heart lengthwise will not cause any change in the rhythm of the two parts; each will continue its activi- ties as before the incision. If an auricle be cut into several ANATOMY OF THE HEART 2$ pieces, each piece will still pulsate. Mitchell {American Journal of Medical Sciences, Volume VII, p. 58) inflated the heart of a sturgeon with air, and it continued to beat after removal from the body, until the auricle became so dry that it rustled during its movements. The irritability (property of reaction to stimuli) of the heart of the higher mammalia is of greater duration in very young animals. This experimental fact agrees with the law that the very young of the higher mammalia resemble the cold-blooded vertebrates, in the power of sustaining life for lengthened periods without oxygen. There are two modes of stopping the heart's action, i.e., by diminishing the strength of the systole, or by increas- ing the length of the diastole. It has been found that the contractile power of the right side of the heart continues long after the left side has ceased to react to stimuli. The exact mode in which each part of the heart comes into a state of rest, or death, has not been determined. It has been found that the ventricles cease first to contract; the left auricle stops entirely; finally the right auricle stops as a whole; but a most distinct peristaltic movement may follow along the auricular appendix, which finally gives place to a gentle fibrillar tremor, and the heart is at rest forever. As the heart beats more and more slowly, there is a marked interval between the auricular and ventricular con- tractions. (" Reference Handbook of the Medical Sciences," Articles, Circulation of the Blood; Thorax.) The heart will beat rhythmically aside from the body even if entirely deprived of blood. Reaction to stimulation of the intracardiac ganglia will be manifested by the livelier action of the heart, but the influence is lost sooner and the heart will come to rest more quickly than if the stimuli be applied elsewhere. External pressure will cause a variation in the rhythm of the heart's action, but the heart-beat will be more vigorous. 24 THE SURGERY OF THE HEART The effect of a blow near the umbilicus, in causing the cessation of the heart action, proves the intimate connection existing between the cardiac nerve mechanism and the sym- pathetic nerve system, since the inference is very plausible that the stoppage is produced by reflex inhibition, conveyed through the sympathetic system. In a former paragraph reference was incidentally made to post-mortem changes in the heart. Another has been remarked regarding the ventricles; it is said that in a well- marked state of rigor mortis the ventricular cavity will be found obliterated, on making a transverse section. The connection between the action of the heart and the function of respiration is of great practical importance in operative surgery. In all studies of the mechanics of the heart action it must be kept in mind that the respiration is the most important of all the dynamic agents which affect this action. The existence of extracardiac centres of nerve force which exert a remarkable influence on the heart beat, has been discovered. These extracardiac centres are in juxtaposition to the respiratory centre; hence it may be justly inferred that they too are influenced by the effects produced by variation in the volume of oxygen contained in the blood supply. Obsen^ation has show^n an alteration in size of the heart W'ith each pulsation; this causes a rhythmical compression of the adjoining lung tissue. The process by which part at least of this effect is produced, has been explained as fol- lows: The branches of the pulmonary artery receive acces- sion of blood at each right ventricular contraction ; this causes them to expand rhythmically in accord wath the heart- beat. The periodical expansion of the arteries produces a corre- sponding compression of the bronchi. There is nothing extraordinary in this, since it has been remarked by com- parative anatomists that this " cardio-pneumatic movement " ANATOMY OF THE HEART 25 is a factor in changing the air in the kings of hibernating ani- mals. CHnical experience in certain diseases where there is great dyspnoea, has shown that the dyspnoea, if prolonged, makes the left ventricle beat feebly sooner than the right, so that the left side of the heart becomes congested. This dams back the blood into the pulmonary veins. This may be a probable cause of the pulmonary oedema observed in the death agony. The influence of the respiratory function is apparent not only in reference to the cardiac movements, but also in reference to the arterial circulation. The expansion of the chest, in respiration, relieves the extracardiac pressure; and the contraction of the chest in expiration increases the press- ure upon the heart, thus producing a higher arterial tension. There is a double aspiration carried on by the chest and by the heart itself. Dogiel says that " artificial respiration slows the blood current and may interrupt it, until dyspnoeic stimu- lation of the respiratory centres results." Zuntz claims that " opening the chest wall annuls its aspiration." Beneke found that the pulmonary pressure is relatively higher in a child than in an adult. Lichtheim says that the plugging of one branch of the pulmonary artery will not necessarily alter the aortic pressure. " No known method will cause a permanent general alteration, of any extent, in the blood pressure of the whole body." (Cohnheim.) The work done by the heart is enormous. The pressure within the cardiac cavities is also considerable; there is both a positive and a negative pressure. The negative pressure of the right ventricle equals two-thirds of an inch of mer- cury; that of the left ventricle equals from two inches to two and four-fifths of an inch of mercury. Part of this negative pressure of the left ventricle is due to active dilatation. This has been found to equal four-fifths of an inch of mercury. Positive pressure in the right auricle equals four-fifths of an 26 THE SURGERY OF THE HEART inch of mercury. At each diastole the pressure in both auri- cles sinks below the atmospheric pressure (fifteen pounds to the square inch, thirty-nine inches of mercury). Opening the thorax in operations is said to cause a fall in blood pressure. Part of this loss of pressure is due to the active muscular action (dilatation of the auricle itself inde- pendently of respiration). The negative pressure in the right auricle is equal to one-third of an inch of mercury. Work done by the right ventricle is only one-third of that done by the left ventricle. The work done by the right ventricle is equal to one and one-eighth foot pounds. The work done by the left ventri- cle at each systole equals three and three-eighths foot pounds. The total work done by the heart, or rather by the two ventri- cles, equals four and one-half foot pounds. It has been estimated by Haughton that the mechani- cal energy expended by the heart in twenty-four hours, equals one hundred and twenty-four foot tons. Taking seventy years as the limit of a man's life, the work done by a normal heart in a lifetime of this length will equal three million one hundred and twenty-four thousand and eight hundred foot tons, a force too stupendous to be grasped. A force of this magnitude would move a train of fifty-two of the largest freight cars loaded to their fullest capacity (twenty tons), over one-half of a mile. In the several veins the blood-pressure varies greatly, but it always diminishes toward the heart. Change of position will have a greater effect upon the venous pressure than on the arterial. The pressure in all the large veins at the heart has been found to be always negative. (Ludwig, Volkmann, Weyrich.) W. G. Thompson says that he experimentally proved the statement. The force of each systole — the work of the heart — is one-tenth greater than the arterial resistance. The blood was driven around the entire circulation by an equal force ANATOMY OF THE HEART 2/ produced by the pressure of mercury. (In all references to mercurial pressure it must be remembered that it is in addi- tion to the atmospheric pressure of fifteen pounds to the square inch, or thirty-nine inches o£ mercury.) An amount of blood equal to one-half or two-thirds the whole volume normally found in any of the higher verte- brates, may be injected or transfused, without danger to the animal injected. Death follows the injection of a volume of blood equal to one and one-half times the normal volume. But, however large the volume of blood injected may be, short of death, the increase is temporary only; the blood soon shrinks to the volume normal to the animal. The nor- mal volume of blood cannot be increased by the ingestion of any amount of food. Increase of the watery element of the blood produces only a temporary increase in the total volume of the blood. Loss from haemorrhage does not cause a permanent diminution, but the loss of the watery element in certain diseases will cause a diminution in the volume of the blood. In such cases the blood becomes dark, almost black, and of the consistency of tar. The color of the blood varies considerably, but as a rule the arterial blood is brighter than the venous; pure arterial blood has a vivid red color. Any impurity, any difference in oxygenation, and even the slightest admixture of impure blood will cause a decided change in color. Truly arterial blood is nearly saturated with oxygen, and the plasma con- tains only a small amount of carbon dioxide. The process of coagulation has an important practical bearing in operative surgery. Coagulation of the blood is caused by the formation of fibrin. Fibrin does not exist pre- formed in the blood, nor is it held in solution in the plasma, as was once thought. It is formed by the action of fibrino- gen and fibrinoplastin in the presence of a certain ferment. The plasma holds the fibrinogen in solution, and the white corpuscles contain the fibrinoplastin, or paraglobulin, and 28 THE SURGERY OF THE HEART also the ferment. The fibrinoplastin and ferment are set free by the death .of the white corpuscles. The fibrinoplastin, thus freed, is acted upon immediately by the fibrinogen, under conditions that permit chemical action. The ferment does not seem to take any active part in this process, but per- forms that inexplicable function observed in many chemical reactions. Many chemical combinations can be produced only when the constituent elements act upon one another, in the pres- ence of some substance, which forms no part of the resultant substance, and does no discoverable work in the chemical reaction. When, from any cause, there is loss of lining endothelium, white blood-corpuscles adhere to the denuded spot, and by their death bring about the formation of fibrin. If infection occurs, the presence of micro-organisms or the chemical compounds, however formed, resulting from their presence, will cause a septic or putrid softening under the above circumstances. 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Phillippo, Edinburgh Medical Journal, 1862, VII, 684. Pettigrew, J. B., Philadelphia Tr., London, 1864, CLIV, 445- 500; 5 Pl- Sokollovski, Moskov Medical Gazette, 1866, 332-334. Brandt, A., Melanges Biol. Acad. imp. d. Sc. de St. Petersburg, 1866, VI, 101-114; Also Transl. (Abstr.). Med. Vestnik, St. Petersburg, 1866, VI, 74, 87. Gegenbauer, C., Jenaische Ztrchr. f. Med. u. Naturw, Leipzig, 1866; II, 365-375- Luton, De Med. et Chir. Prat., Paris, 1868, VIII, 249-324. BucHDALEK, J., Arch. f. Anat. Physiol, d. Wissen. Med., Leipzig, 1868, 302-325. GooDSiR, J., In his Anat. mem. 8, Edinburgh, 1868, L, 443-445. 30 THE SURGERY OF THE HEART ToNGE, M., Philadelphia Tr., London, 1869, CLIX, 387-411 ; 2 pi. Fritch, G., Arch. /. Anat. Physiol, u. Wissen. Med., Leipzig, 1869; 654-758; 4 pi. (also reprint). CEllacher, J., Arch. }. Mikr. Anat., Bonn, 1871, VII, 157-165. CouGHTREY, M., Proc. Lit. and Philadelphia Society, Luerp, 1873, XXVII, 327-333- Skvortsoff, St. Petersburg, 1874. Parrot, Compt. Rend., Societe de Biologie, 1876. Paris, 1877, 6 s. III, 97-100. DoGiEL, J., Arch, de Physiol, norm, et path., Paris, 1877, 2 s., IV, 400-408; I pi. Dareste, C, Jour. d'Anat. et Physiol, etc., Paris, 1877, XIII, 249-266. Gasser, E., Geselbch. z. Bedford d. ges. Natura zu Marb., 1876, 39-42; Arch. }. Mikr. Anat., Bonn, 1877, XIV, 459-470; 2 pi. Darwin, F., Jour. Anat. and Physiol., London, 1876, II, 506-510. (On the structure of the snail's heart.) Priestly, J., Jour. Physiol., London, 1878, 1, 1-38. DuRAND, Lyons, 1879. Fenn, M. C., Western Lancet, San Francisco, 1879-80, VIII, 104. Huxley, T. H., Nature, London, 1879-80, XVI, 5. Cadiat, Bull. Acad, de Med. Paris, 1879, 2 s., VIII, 69-71. Herrmann, L., Handbuch der Physiol, B. IV, 1880. PiTRES, Journal de Medecine de Bordeaux, 1880-81, X, 301, Huxley, Tr. of the Medical and Chir. Fac. of Maryland; Bahi- more, 1881, LXXXIII, 192-205. QuENN, Paris, 1883. Ferguson, J., Canadian Prac, Toronto, 1883, VIII, 228-230. ToisoN, Paris, 1883. Henke, Construction der Lage des Herzens in der Leiche aus einer serie von Berlin. Herrmann, L., Experimental Pharmacology, trans, by R. M. Smith, 1883; p. 113. Robertson, J., McG. Elements of Physiol. Physics, 1884, London. RiCKETTS, B. M., Observations on the Heart of a Tortoise, Ex- perimental, Virginia Medical Monthly, March 10, 1899. CHAPTER II EXPERIMENTAL RESEARCH In reviewing the literature pertaining to the experimental research referring to the surgery of the heart, little is found as compared with that bearing on the physiology of the heart. Physiologists have offered but little if any encourage- ment in dealing with cardiac injuries. What has been done experimentally and with injuries to the human heart has been independent of the teachings of the physiologist. As soon as the investigator had concluded his work upon the lower animals (and every such investigator appears to have been a surgeon) he reasoned from animal to man, and justly so, as proven by subsequent events in the domain of surgery upon the human heart. Historical. — Hering was the earliest to ascertain the rapid- ity of the circulation. He introduced prussiate of potash (cyanide of potassium) into one part of the system and drew blood from another. Legallois, in 1813, experimented on the principle of life, and particularly on the principle of the motion of the heart and on the seat of this principle. Witt- bank, in 1824, made a series of experiments to determine the cause of the action of the heart. Hope, in 1830, entered into an experimental and clinical study of the physiology of the heart's action. Brown-Sequard, in 1853, Chauveau, in 1856, Halvord, in 1858, Upham, in 1859, Berner and Flint, in 1 861, and Bernard, in 1879, each made an extensive exper- imental study with reference to the heart's action. Roberts, in 1881, determined from experimental investi- gation that puncture of the heart with suture of it would 31 32 THE SURGERY OF THE HEART become a therapeutic measure. Block sutured the cut ven- tricular wall of a rabbit in 1882. It was not until 1884 that Howell and Donaldson made their experiments upon the dog. Sewall, in 1884, conducted experiments with reference to the physiology of the intermittent heart. Kronecker and Schmey, in 1884, showed by experiments upon rabbits that needle puncture at a certain point in the saeptum between the ventricles produced death by injuring the large nerve ganglia, which are derived only from the sympathetic. The influence is, therefore, sensory and not motor. Pennock and Moore also experimented to determine the action of the heart. Senn, in 1885, made an experimental and clinical study of air embolism (thirty-nine experiments on dogs). He showed that it was possible to remove air from the cham- bers of the heart by means of an aspirating needle without fatal results. Phillipson made experiments to determine the advisability of applying sutures in wounds of the heart. This was in 1886, and he was followed by Del Vecchio in 1895, who showed by experiments upon dogs the possibility of suturing heart-wounds in man. Cohnheim showed that pressure in the pericardium from fluid was upon the auricles, that the ventricles would con- tinue to contract, and that sufHcient pressure would stop contraction of both auricles and ventricles. Romberg showed, before nerves and ganglia were found in the cardiac muscle, that the foetal heart contracted rhythmically. Porter says that the cause of rhythmic contraction of the ventricle lies in the ventricle itself. (Journal of Exp. Med., I, 1895, p. 319.) Ten out of sixty animals, though their hearts had ceased to beat, were restored to life by the puncture, and com- pletely recovered. One of them, indeed, after two experi- ments, recovered twice. All except one puncture in the ten cases were made in the right ventricle. These experiments were made by Watson and are referred to by Paget. 1897. EXPERIMENTAL RESEARCH 33 They demonstrate in a beautiful manner that such means of cardiac stimulation may, at times, be beneficial, now and then completely restoring life. Crile, in 1897, showed that gunshot wounds of the heart, not penetrating the chambers, caused but temporary arrhythmia for several beats. Dana, in 1897, stated that he had often punctured the heart in animals, and by so doing had stimulated and never checked it ; but he got no results in two cases in practice. Elsberg, in 1899, made a most elaborate experimental investigation of the treatment of wounds of the heart by means of suture of the heart-muscle. He has shown con- clusively that suture of open wounds of the heart is a most rational procedure. How^ever, it had been successfully ac- complished in man in 1896. Elsberg thinks there is much doubt as to the existence of new muscle fibres in hypertrophic hearts, especially in the longitudinal diameter of old fibres. But connective tissue may degenerate; if it does, the normal tissue surrounding it does not seem to do so. He further says that muscle fibres are destroyed by trauma and replaced by connective tissue, but the change does not interfere with cardiac function. In one of his experiments he amputated the apex of the heart, necessitating the opening of one of the ventricles, and sutured the cut surfaces together with- out loss of the rabbit's life. Brunton {Journal of the Amer. Med. Ass'n., March, 1902. p. 589) has conducted a series of experiments upon cats and the dead human body to show the possibilities of surgical operations for mitral stenosis. He states that not only should the pericardium be opened for the operation, but that it should be left open to give exit to any oozing or haemorrhage, as the heart has little power to resist rapidly occurring intrapericardial pressure. He also says that haemorrhage is greater from a needle puncture in the auricle than in the ventricle, even though the same needle be used. N. I. Botcharoff made pharmacologic experiments on the 34 THE SURGERY OF THE HEART isolated heart of warm-blooded animals. Villar conducted experiments upon suturing wounds of the hearts of animals. H. M. Sherman reported his observations on experimental heart surgery. G. V. N. Dearborn, in 1903, made a physiolog- ical study on a crustacean heart. " Conclusions — The operations which have been recorded mark only the beginning ; the heart is now destined to be sub- mitted to many manipulations, provided they may be done without stopping its action at once. It is a very unsafe thing to prophesy, but that more will be attempted can easily be in- ferred, for interference with the mitral orifice has already been si-^ggested and the immediate neighborhood of the heart has been invaded and a sacculated aneurysm of the aorta has been tied off, the success of this well-executed maneuvre being pre- vented only by the failure of the atheromatous vessel walls to heal. Possibly the next step may be delayed as long as the application to the heart of common surgical methods was de- layed after Desault had taught us to open the pericardium. Perhaps it may come soon. It is not impossible that a new surgical technic may have to be created, but it is most proba- ble that the next step will be based on the new application of the very old matters of suture and drainage." (H. M. Sherman, Suture of Heart Wounds, Journal American Medical Association, 1902, xxxviii, 1 560-1 568.) Surgical Shock — " Surgical shock is in all probability allied to the physiological phenomenon of inhibition, but differs from the physiological condition in that it involves to a greater or less degree the entire nervous system. An inhibi- tion of unimportant areas is not likely to be followed by serious results, but an inhibition of vital centres will prove fatal if severe or long continued. " Of the important nerve centres in the nervous system, the vasomotor centres take first rank. Hence, in surgical shock it is the vasomotor inhibition which calls most urgently for treatment. EXPERIMENTAL RESEARCH 35 " It is necessary to keep in mind the fact that vasomotor collapse involves principally the arterioles; the heart, prob- ably through its connection with the nervous system, is also implicated, but much less seriously. The heart is an organ that will stand a great many insults and much hard treat- ment, as those who work on lower animals are aware; but the vasomotor system is exceedingly sensitive and imme- diately resents any abuse by causing a relaxation of the arterioles throughout the body. In consequence of this, the blood pressure falls, the pulse weakens or disappears, and unless some heroic method of resuscitation is adopted the patient dies of collapse. The heart continues beating for some time after the arterioles relax, but its contractions are feeble and often irregular. Later on, the heart stops its contractions; but here again the cause lies not so much in the heart as in the falling blood-pressure produced by the relaxed arterioles. When the blood pressure sinks, blood can no longer be forced into the coronary arteries, and the heart stops in consequence of a lack of oxygen. It is for this reason that the mammalian heart does not beat rhythmi- cally when excised from the body; its removal stops the coronary circulation, and the organ ceases its beating. When defibrinated blood Is transfused through the coronary ves- sels, the mammahan heart can be made to resume its con- tractions outside of the body. It is the vasomotor system, then, rather than the heart, which requires treatment in con- ditions of sudden collapse. " There is another factor in vasomotor collapse which must not be overlooked. When, in consequence of overstimu- lation or of some poison in the blood, the vasomotor centres give way and the arterioles relax, the circulation in the cen- tral nervous system, where vasomotor centres reside, is inter- fered with. As a result less blood circulates through the brain and the spinal cord, and therefore less blood is carried to the failing vasomotor centres. A vicious circle is estab- 36 THE SURGERY OF THE HEART lished in this way, and eventually the blood-pressure sinks to nil, unless we can l^reak the vicious circle and give the vasomotor centres a chance to recover under an increased blood supply. Strychnine and whiskey act principally by direct stimulation of these centres, and their administration is followed by the desired results, provided the nerve cells are not beyond the capability of reaction. When, however, the nerve cells are powerfully shocked, a direct stimulation depresses rather than stimulates them. " The injection of normal saline solution is then more likely to be followed by favorable results, because the liquid, by mechanically filling the blood-vessels, partially compensates for the loss of tone produced by the relaxed arterioles. If the vasomotor centres are not too seriously involved, they react under the increased blood supply brought about by the injection, and recovery results. But. as all surgeons know, even the normal saline solution occasionally fails to do its work properly; in fact, we found in our experiments that even copious injections were accompanied by a distinct fall of pressure in animals suffering with severe vasomotor shock. " Adrenalin, according to Takamine. is the active princi- ple of the medulla of the suprarenal bodies. When injected into the circulation, it causes an enormous rise in blood press- ure, due not so much to the stimulation of the vasomotor centres as to the direct stimulation of the heart and arterioles. It produces its effects almost as well on the heart and blood- vessels isolated from the central nervous system as when they are in physiological connection with their nerve centres. When it is injected directly into the blood stream of an ani- mal, the rise is prompt, powerful, but not prolonged. The remedy appears to be very rapidly destroyed or neutralized in the blood, or more probably in the tissues. In adrenalin, then, we have an agent which can rapidly overcome vaso- motor shock by acting, not on the centres themselves, but Plate VI. X IGO. Transverse Section of Cardiac Muscular Fibres and Capillaries. (Dr. A. V. JNIeigs.) X 00. Transverse Section of Cardiac Muscular Fibres. (Dr. A. A'. ^leigs.) (Anatomy of the Heart.) EXPERIMENTAL RESEy\KC,II 37 directly on the heart and arterioles, but which unfortunately is very evanescent in its action when injected into the blood. In order to make it a useful remedy for the treatment of the condition under consideration, its action must be made more prolonged and preferably less powerful. " In a research undertaken by Dr. May Miles and myself, we found that when the adrenalin was diluted to one in ten thousand and about one cubic centimetre was injected hypo- dermically, the vasomotor collapse consequent on ether poi- soning could be completely overcome. The blood pressure in the rabbits experimented on rose rapidly and remained elevated for two hours or longer. The site of the injection must be vigorously massaged in order that absorption may be promoted. We inferred from these experiments that adrenalin in the strength and by the method indicated would be a valuable remedy for surgical shock. The increased blood pressure, by improving the circulation through the central nervous system overcomes the inhibition and permits a restitution to a normal physiological tone." — William Muhl- berg, M.D. BIBLIOGRAPHY Hering, Tiedemann's Zeitschrift, Vol. Ill, p. 85. Valentin, Lehrhuch der Physiologie, Verhandlung I, p. 427. Legallois, C. J. J., Transl. by N. C. & J. G. Nancrede, Phila- delphia, 1813. WiTTBANK, J., Phila. Journal Med. and Chir. Soc, 1824, IX, 361- 376. Hope, J., London Med. Gaz., 1830, VI, 782-935. Pennock and Moore, Med. Examiner, Philadelphia, 1839, II, 695-697. Blake, Edinb. Med. and Surg. Journal, Oct., 1841. PoiSMSiLLE, Ann. des sci. nat., 1843, zool. torn. XIX, p. 32. Weber, Arch, d' Anal. Gencr, et de Physiol., Jan., 1846. 38 THE SURGERY OF THE HEART Brown-Sequard, Experimental researches applied to Physiology and Pathology, New York, 1853. Chauveau ex Faivre, Gaz. Med. de Paris, 1856, 3 s., XI, 365, 406, 457- Halford, G. B., Med. Times and Gaz., London, 1858, XVI, 109, 191, 391. Upham, J. B., M. Groux, Boston, 1859. Berxer, H., Lehre von der Herzbewegung, Erlangen, 1859. Flint, A., Am. Jour. 0} the Med. Sc, 1861, XLII, 341-381. Halford, Lancet, London, 1867, 1, 19. Bernard, C., Physiologic operatoire, 1879, Paris. Roberts, John B., Tr. of the College of Phys. and Surg., Phila- delphia, 1881-3; Vol. VI, 215-219. Howell and Donaldson, Phil. Trans, of the Roy. Soc, Part I, 1884, p. 139, London. Sewell, H., Phys. and Surg., Ann Arbor, 1884, VI, 145-150. Kronecker and Schmey (Sitzungsberichte d. Berliner Akad., 1884, p. 87. Senn, Trans, of the Amer. Surg. Ass'n., 1885, Vol. Ill, p. 187. Phillipon, Russian Medicine, St. Petersburg, 1886, IV, 187. Romberg, Deutsche Med. Wochenschrift, 1889, p. 549. Krehl, Deutsche Med. Wochenschrift, 1889, p. 549. Kolster, R., Experiment Studium iiber de und regenerative vor- gange am Herzmuskel bei Gefasssperre (Myomalacia cordis, Ziegler), Res. pp. XLIII-XLV, Festskr. f. path. anat. Inst. Helsingfors. ScHAEFER, Verhandl. d. IX Congress f. innere Medicine, 1890. His, W., and Romberg, Arch. }. exp. Path. u. Pharni., 1892, XXX, 51- Delorme, Chir. dc guerre, 1893. Del Vecchio, Riv. Med., April 4, 1895. Porter, Jour, of Exper. Med., 1895, I, 319. Rosenthal, Deutsche Med. Woch., 1895, No. 2. Engelman, Archiv. f. d. ces. Phys., 1896, LXV, 119, 535. Delorme et Mignon, Revue de chir., 1895, pp. 797-987, and 1896, p. 56. EXPERIMENTAL RESEARCH 39 Salomoni, Centralbl. j. Chir., 1896, No. 51. VoiNiTCH-SiANOjENSKY, Arcliiv. Tuss. de chir., St Petersburg, 1867, II. Rehn, Langenbeck's Arch., 1897, LV, 315. Bode, Beitrage z. klin. Chir., 1897, XIX, 167. Elsberg, C. a., Journal oj Exper. Med., Baltimore, Vol. LV, Nos. 5, 6, Sept., Nov., 1899. LoisoN, Revue de chir., 1899, Nos. i, 2, 3. Rose, Deutsche Zeitschr. /. Chir., XX, 329. MoRGAGNi, De sed. (et caus.) Morborum, Expert 69, Sect. 5. CoHNHEiM, Allgem. Path., 1. RiEDiNGER, Krankheiten des Thorax, Deutsche Chir., XLII, p. 180. KoNiG, Lehrbuch d. Chir., II. Crile, G. W., Exper. on shock, 1900 and 1901. RiCKETTS, B. M., Transactions of the Western Surg, and Gyn. Ass'n., 1901-2. RiCKETTS, B. M., Jour, oj the Am. Med. Ass^n., Nov. 15, 1902, p. 1245. Sherman, H. M., Jour. 0} the Am. Med. Ass'n., 1902; XXXVIII, pp. 1560-65. RiCKETTS, B. M., Transactions of the Carolinas and Virginia Tri-State Med. Soc, 1903. Dearborn, G. V. N., Med. News, March 20, 1903, pp. 596-601. CHAPTER III CARDIAMORPHIA etiology — Embryologists claim that the s^eptum of the auricle is completed by the sceptum growing backward, as it were, and uniting with the saeptum intermedium. How- ever, before this process is completed, several other changes occur, while the superior saeptum is forming the saeptum inter- medium is also in a state of formation, and between these two saepta at this stage of development there is an opening which was formerly thought to be the origin of the fora- men ovale, but Bern and other investigators have shown that a secondary rupture occurs in the superior sseptum. The opening thus formed by the secondary saeptum of the superior saeptum becomes the foramen ovale. It is very probable that many of the cases of patency of the foramen ovale which have been reported have not been in fact what they were thought to be. There is a very great possibility that the condition observed was due to an arrest in the nor- mal development of the embryo's heart. The opening that is found between the superior saeptum and the saeptum intermedium has never been closed, either because the union of the two saepta has been hindered or because further development of this part of the heart has ceased from some cause. In other cases the effect may have been produced later. Some cause may have prevented the development of the sec- ondary saeptum, or it has not conformed to the changes which have taken place. It is not enough of a secondary saeptum to make (also) a valve for the foramen ovale. 40 CARDIAMORPHIA 4I The heart may be abnormally small (hypoplasia). Vir- chow says that such a condition is most frequently found in chlorotic persons — the haemophiliacs. Two or more imper- fect hearts may be found in the same chest. Atrophy of the heart's walls may occur without lessening the size of its chambers. Malformations of the heart are of many varieties, and they all vary more or less in degree and must necessarily be considered in a work of such a character as this, the object being to present those defective hearts that will best illustrate the object intended, namely the surgical features. Mal- formations and anomalies must of necessity be considered together, while displacements and malpositions can be similarly classified. No doubt death from non-closure of the foramen ovale is less frequent than is generally supposed, other abnormities being the cause. Autopsies are secured in but a small per cent, of such cases. Historical (1675-1903). — Openings between the ventricles may be congenital or acquired, and are of many varieties, degrees, and locations, as shown by the various reporters, among whom Marshall, in 1830, mentions a very interesting case, as does Bertody, in 1845, a-^so, when he reports a case of communication between the ventricles of the heart, the aorta originating from both ventricles. In the case of Par- ker, in 1846, the aperture was in the saeptum of a heart having considerable contraction of the pulmonary orifice, with the aorta arising entirely from the right ventricle. Ouain (1846) showed a congenital perforation at the base of the saeptum ventriculorum. A similar one is mentioned by Bennett (1846), but that of Peacock (1848) was a much larger fora- men ovale than is usually found dependent upon contraction of the aortic orifice. In the case of Mayne (1847) the open foramen ovale had caused remarkable derangement of the circulation. In Jenner's cases (1848) the subjects did not 42 THE SURGERY OF THE HEART have any disturbance of the circulation, but in that of Lloyd (1848), there was considerable dilatation of the right side of the heart. None of these manifestations was displayed in the case of Wienholt (1848). However, there was great cyano- sis in a case reported by Lee (1849), in which the opening between the ventricles was near the mouth of the aorta, with contraction of the pulmonary artery. One of the most inter- esting of the pathological conditions of this type of anomalies is reported by Hutchinson (1853), in which he mentions a malformation of the heart in a child who had suffered from cyanosis. There was an imperfect ventricular saeptum, with a rudimentary right ventricle which had been divided into two chambers by a fleshy saeptum between its sinus and its infundibular portion. Peacock (1859) reports a large open foramen ovale without cyanosis, while Callender's case revealed a perforation of the saeptum ventriculorum with clots in some of the pulmonary arteries undergoing various changes. Wagstaffe (1868) re- ports two cases of free communication between the auricles by deficiency of the upper part of the saeptum auriculorum in persons aged fifty-two and six years respectively. There was no cyanosis in either case. In the case of Holt (1884) there was an open foramen ovale and an open ductus arteriosus with stenosis of the aorta and hypertrophy of both ventricles. Haddon (1890) reports a case in which there was a patent foramen ovale in an adult, and Griffith (1896) mentions a case of perforate saeptum ventriculorum and remarks on its diagnosis. Solomon (1898) reports a case of patent foramen ovale and an extra coronary artery. Aorta and Pulmonary Artery — Transposition or oblitera- tion of the pulmonary artery is quite common. It may open into any one or all of the cavities of the heart, as may the aorta also. Indeed, the pulmonary artery may connect with the aorta directly. Reid (1835) reports a case of oblitera- tion of the vena cava superior at its entrance into the heart, CARDIAMOKl'IIIA 43 while West mentions a case of malformation of the heart and great vessels attended with cyanosis. In the case of Bertody (1835) not only did the aorta originate from both ventricles, but there was a communication betw^eeii them. In the diseased heart reported by Dalrymple (1846) the root of the aorta had an opening common to the ventricles. In Parker's case (1846) the aorta arose entirely from the right ventricle. Cheever (1846) reports a case illustrating the earliest stage of malformation, usually known as distri- bution of the descending aorta from the pulmonary artery. Peacock (1847) reports a case of malformation of the heart in which death resulted from obstruction in the trunk of the pulmonar}^ artery. He again reports (1848) a case in which there was contraction of the pulmonary orifice which par- tially originated from the right ventricle. In the case of Canton (1848) there was complete oblitera- tion of the origin of the aorta. In Ward's (1850) case there was transposition of the aorta and pulmonary artery. Grieg (1852) mentions a case in which the pulmonary artery was given off from the descending aorta and left subclavian artery. In the case of Peacock (1853) there was great con- traction of the pulmonary orifice with deficiency of the s?ep- tum ventriculorum and open foramen ovale. In another (1855) both auricles opened into the left ventricle and there was transposition of the pulmonary artery and aorta. In still another (1859) he reports absence of the ductus arterio- sus with a small-sized pulmonary artery and the aorta aris- ing from both ventricles. There was great irregularity in the course of the aorta. In the case of Baly (1856) the pulmonary artery was impervious at its origin. In the case of Schilling (1857) there was an abnormal arrangement of the larger vessels to the heart. Abrahamson, in 1857, reports a case in which there was partial obliteration of the ascending aorta. Meigs, in i860, 44 THE SURGERY OF THE HEART briefly reports a case in which there was transposition of the heart's vessels. Nunneley (1862) writes extensively on a condition which he found, in which the aorta freely communicated with both ventricles, and these with each other; the walls were small and thin and the pulmonary artery had a small slit-like open- ing into the ventricle. There was an open foramen ovale. Cockle (1863) reports a case in which there was transposi- tion of the great vessels of the heart. Peacock (1864) re- ports a case in which there was obliteration of the orifice of the pulmonary artery, with an open foramen ovale and ductus arteriosus; there was cyanosis. In another case which Pea- cock mentions (1869) there was atresia of the orifice of the pulmonary artery, and the aorta communicated with both ventricles. He speaks of a similar case the same year and of another one in 1870. During this year (1870) he reports a case of great contraction of the pulmonic orifice, the aorta arising from the right ventricle, but communicating with the left by an aperture in the sa?ptum ; he also reports this year (1870) a case of almost complete separation between the sinus and infundibular portion of the right lung, the aorta arising from both ventricles. Green (1867) reports a case of malformation of the heart with absence of pulmonary artery and the aorta springing from the right ventricle. The s?cptum ventriculorum was in- complete and there was a patent foramen ovale. Vulpian (1868) speaks of a case of complete obliteration of the orifice of the pulmonary artery. Plickmann (1869) reports a case of malposition of the heart and transposition of the auricles and aorta; there was absence of the pulmonary artery and the foramen ovale was patent, communicating with the ventricles, with lateral transposition; there was visceral cyanosis. Again, Hickmann (1869) reports a case in which there was transposition of the viscera, with malformation of the heart, the i)ulmonary veins from the right lung enter- CARDIAMORPHIA 45 ing the left auricle and those horn the left lung entering the right auricle. Allis (1871) reports a case of malformation of the heart in which there was stenosis of the pulmonary artery, per- foration of the ventricular s?eptum, and dilation of the right ventricle. Rex (1874) reports a case of congenital malforma- tion of the heart, contraction of the pulmonary artery, and deficient ScTptum ventriculorum, the aorta originating from both ventricles. There was no cyanosis. Janeway (1877) reports a case of malposition of the pulmonary artery anc^ aorta, thrombosis in the heart, cerebral embolism, and death from intestinal haemorrhage. Archer (1878) reports a case in which there was a congenital band across the origin of the aorta. Stone (1878), from among his clinical cases, re- ports a congenital malformation of the heart without a pul- monary artery. Peacock (1876) reports stenosis at the commencement of the conus arteriosus, at the right ventricle, and at the origin of the pulmonary artery. The aperture in the saeptum ventriculorum and aorta arose partly from the right side. The foramen ovale and ductus arteriosus were closed; there had been cyanosis. In another which he reports (1880) there was great stenosis of the orifice of the pulmonary artery, the aorta arising from both ventricles. There were defects in the folds of the foramen ovale, but the ductus arteriosus was closed. Lees (1880) reports a case of malformation of the heart with transposition of the aorta and pulmonary artery. Shat- tock (1881) reports atresia of the aortic orifice in an infant, while Ashley (1881) records a case of transposition of the aorta and pulmonary artery in a child seven months old. One of the most interesting cases of this class of anomalies is reported by Cronk (1881). The aorta arched over the right bronchus and the pulmonary artery closed about the semilunar valves. Abercrombie (1882) reports a case of con- 46 THE SURGERY OF THE HEART genital atresia of the right ventricle with patency of the duc- tus arteriosus. Livingstone (1883) reports on a congenital communica- tion between the right side of the heart and the beginning of the aorta. Meyer (1883) mentions a case of cyanosis due to congenital defects of the aortic orifice. The child lived twenty-seven days. Bury (1884) reports a case of con- genital contraction of the orifice of the pulmonary artery from fusion of the valves, the foramen ovale being open. Again, in 1887, he notes a case of congenital malformation of the heart, congenital atresia of the conus arteriosus, m- complete saeptum ventriculorum, and the aorta arising mainly from the right ventricle. Little (1880) reports a case of ab- normity of the great cardiac vessels with absence of the superior vena cava. Habershorn (1887) reports a congenital malformation of the heart and kidneys with obliteration of the pulmonary artery, the aorta arising from the right ventri- cle. There was imperfection of the saeptum ventriculorum, and the lungs were supplied from the aorta by a large ductus arteriosus dividing into right and left pulmonary branches. There was a horseshoe kidney. De Renzi (1889) reports three cases of abnormity of the heart and one of the great vessels also. Cadet de Gassicourt ( 1890) reports a case of mal- formation of the pulmonary artery. Howard ( 1892) reports a case of congenital malformation of the heart and atresia of the pulmonary artery with persistence of the foetal circulation. Stuertz (1894) mentions a case of obliteration of the aorta. Nazarofif (1895) reports a congenital deformity of the heart (narrowing of the cone and the orifice of the pulmonary artery with an opening on the intraventricular and interauric- ular saeptum), so diagnosticated during life and confirmed by autopsy. Bovaird (1895) reports two cases of congenital cyanosis due to stenosis of the pulmonary orifice with an interventricular foramen. Holt (1895) reports a malforma- Plate VII. Traxs\-]-.rse Section of Hzart, ^/l inch from Apex. Transverse Section of Heart. iVj inches from Apex. (Anatomy of the Heart.) CARDIAMORPHIA 47 tion of the heart with puhnonary stenosis, a deficient ventricu- lar saeptum, open ductus arteriosus, and the aorta arising from both ventricles, but principally from the right. Caubet and Baylac (1896) report congenital cyanosis and complete inversion of the viscera. Caille (1896) reports a case of trans- position of large vessels in the heart, as does Rolleston ( 1897), also Gallaverdin ( 1896) reports a case of cardiac mal- formation with absence of the pulmonary orifice. Cavities. — That a human being may live indefinitely with two, three, four, five, or six cavities of the heart has been shown by the various reports herein mentioned. Such facts, however, have been recognized from the earliest writ- ings on anatomy. Foster (1846) reports a heart with only two cavities, while Crisp during the same year men- tions a heart with only a single auricle and ventricle. Ramsbotham (1846) reports the heart of an infant with only one ventricle and auricle. Hutchinson (1853) mentions a case of rudimentary right ventricle, giving the heart five chambers. Dalton (1855) reports a heart in which there were but one auricle and one ventricle. Clark (1857) reports a case of but a single heart. Bradley (1873) reports a tricoelian human heart, while Fenton (1873) reports a heart with five cavities. Heineman (1878) writes exhaustively on a malformed heart in which there was absence of the right ventricular cavity with occlusion of the pulmonary artery. Baldwin (1879) reports a most interesting condition found in a case of malformation of the right heart. There was dropsy involving only the lower extremity and half of the trunk. Stone (1881) reports a case of tricoelian heart with insufficiency of the ventricular saeptum. Turner (1882) re- ports a malformed heart consisting of but two cavities. Schrotter (1887) mentions a case of dextrocardia, while Shattock mentions a heart with a bifid apex. Holt (1890) reports a congenital malformation of the heart resembling 48 THE SURGERY OF THE HEART dextrocardia, with entire absence of the sseptum ventricu- lorum, pulmonary stenosis, and patent foramen ovale. ]Mayer (1892) records a double-hearted freak. Cowan, John, on obstruction of the coronary arteries, Glas- gow Medical Journal, 1902, Ivii, 260-275; 2 fig. Dr. Cowan in a resume states : 1. The coronary arteries may be obstructed — (i) at their origin; (2), in their course. 2. If the obstruction involves a main artery and the clo- sure is gradual, compensatory enlargement of the other artery may prevent damage to the cardiac muscle, but perfect com- pensation is rare, and necrosis or fibroid change commonly en- sues, if, however, the closure is rapid, sudden death is the usual result. 3. If the obstruction involves a small artery no compensa- tory arrangement is possible, and the nutrition of the cardiac muscle will suffer whether the closure is rapid or gradual. 4. (a) If the obstruction is partial some of the muscle may degenerate (granular or fatty degeneration) and may ulti- mately disappear and be replaced by fibrous tissue; (b) If the obstruction is complete some of the muscle will become ne- crosed (infarct) and the patient may die from slow cardiac failure or from rupture of the heart; if, however, the infarct is of small size healing may take place and a fibroid scar be ultimately formed. For other abnormities and for the formation of the heart and its great vessels, reference may be made to the bibli- ography. CARDIAMORPHIA 49 BIBLIOGRAPHY Stenon, U., Ex. variorum animalium sectionibus sine inde factis excerptae observationes circa motum cordis, auricularum et ven- arum cavarum. Ada. Med. et Phil., 1673, Hofn., 1875, H' 141-147. Also transl. Collect. Acad, de Med. etc., Dijon, i757» IV, 246-250. Amynd, C, An extraordinary case of the foramen ovale being found open in adult. Phil. 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Jour, of the Soc. oj Anat., 1816 (Am. ed.), New York, 181 7, I, 49-55; I pi., also Am. Med. Rec, Phila., 1818, I, 214-219; I pi. Andral, De I'etat du coeur chez les monstres a deux tetes ou a deux corps, Jour. hebd. de med., Paris, 1820, VIII, 13. Cheever, C. a., a Remarkable Case of Malformation of the Heart of a Boy of Thirteen Years Six months. New England Jour. Med. and Surg., Boston, 1821, IX, 217-221; i pi. 50 THE SURGERY OF THE HEART Brown, B., Case of Singular Malformation of the Heart. London M. Reposit, 1824, n. s., I, 129. Beckhaus, G., De dcformationibus cordis congenitis, 8, Berolini, 1825. Louis, De la communication des cavites gauches du coeur. Mem. and Researches Anat. Path., Paris, 1826, 301, 350. Manran, J., Account of a Malformation of the Human Heart. Jour. Med. and Phys. Sc, Phil., 1827, XIV, 253-259; 2 pi. Hoffman, R. K., Case of Malformation of the Heart, N. Y. Med. and Phys. Jour., 1827, VI, 250-252. Carter, H. W., Case of Malformation of the Heart. London Med. Repos., 1828, XXIX, 99-101. Campbell, M., An Account of a Malformation of the heart with Morbus Caeruleus, Edinb. Med. and Surg. Jour., i83o,XXXIV, 107-109. Marshall, J., London Med. Gaz., 1830, VI, 886-888. JouRDAiN, Observations sur une affection organique du coeur, Tr. Med., Paris, 1832, VII, 159-176. Ray, Singular Malformation of the Heart. Med. Mag., Boston, 1834, II, 217-234. Berard, Anomalies du cceur. Diet, de Med., 2 cd., Paris, 1834, VIII, 217-229. Bloxam, J. C, Case of Malformation of the Heart. London Med. Gaz., 1834-35, XX, 435. Reid, J., Edinb. Med. and Surg. Jour., 1835, XLIII, 297-301. Stewart, D., Case of Open Foramen Ovale. Tr. of the Med. and Phys. Soc, Calcutta, 1835-42, VIII, 350-353- Frank, De dcformationibus congenitis in generc et cordis in specie, Monachii, 1839. Baron, Une seule artere pour les deux ventricules du coeur. Bull. de la Soc. Anat. de Paris, 1836, X. Cooper, G., Case of Malformation of the Thoracic Viscera, Im- perfect Development of the Right Lung and Transposition of the Heart. London Med. Gaz., 1836, XVII, 600-602. Landouzy, Observations de communication anormale entre les cavites de coeur; persistance du trou de Botal, ouverture a la CARDIAMORPIIIA 5 1 partic moycnnc ct supericure dc la cloison inlcrventriculaire, dilatation avec hypertrophic du ventricule droit, etroitesse congenitale de I'art^rc pulmonairc. Arch. gen. de med., Paris, 1838, III, 436-443- Napper, a., Rare Malformation of the Heart. London Med. Gazelle, 1840-41, XXVII, 793. Joy, W. B., Congenital Malformations of the Heart. Sysl. 0} Pracl. Med. (Tweedie), 1841, III, 568. West, Med. Exam., Philadelphia, 1842, I, 705-709. Carson, J., Case of Malformation of the Heart of Child which Expired on the Fifth Day after Birth; Edinh. Med. and Surg. Jour., 1844, LXII, 134. Aran, A., Congenital Malformation of the Heart. Lancel, 1844, I, 501. Bertody, C, Med. 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B., Tr. of the Path. Soc. of London, 1848-50, II, 183. Peacock, T. B., Sacculated Expansion of the Valve Closing the Foramen Ovale, Tr. of the Path. Soc, London, 1850-52, III, 80. Mayne, R., Dublin, Quar. Jour. 0} the Med. Sc, 1848, V, 46- 59; also abst., Proc. of the Path. Soc. of Dublin, 1847-48, 35- 38. Canton, Tr. of the Path. Soc. of London, 1848-49, II. 38. Jenner, Tr. of the Path. Soc. of London, 1848-49, II, 37. Lloyd, Tr. of the Path. Soc. of London, 1848-50, 1, 223. O'Shaughnessy, R., Case of Congenital Malformation of the Heart. India Roy. Med. Soc, Calcutta, 1848, I, 684-689. WiENHOLT, De communicatione cordis dextri et sinistri. Halis Sax., 1848. Lee, C. a., Buffalo Med. Jour., 1849-50, V, 70-74. Bernard, Conformation anormale du coeur. Compt. rend, de la Soc. de hioL, 1849, Paris, 1850, I, 198. Ward, O., Tr. of the Path. Soc of London, 1850-51, III, 63-65. Greig, Monthly Jour, of the Med. Sc, London and Edinburg, 1852, XV, 28-30. Peacock, Pervious Foramen Ovale, with Emphysema, at Sixty-six Years of Age. J. M. Penus, Ann Arbor, Mich., 1853-54, 1, 213. CARDIAMORPHIA ' 53 Hutchinson, Tr. of the Path Soc. of London, 1853-54, V, 99-101. Ogle, W. J., Abnormal Condition of the Valves at the Root of the Pulmonary Artery with Consequent Hypertrophy of the pari- etes of the Right Ventricle of the Heart, ibid., 1853-54, V, 69- 71- Cabot, Malformed Heart; Interventricular Opening. Am. Jour. oj the Med. Sc, Philadelphia, n. s., XXXII, 351. Dalton, Am. Med. Monthly, N. Y., 1855, III, 224. Buchanan, G., Malformation of Heart, Cyanosis. Tr. of the Path. Soc. of London, 1856-57, VIII, 149. Vernon, H. H., Two Cases of Malformation of the Heart. Med. Chir. Tr., London, 1856, XXXIX, 297-306; i pi. Peacock, T. B., Contraction of Right Auriculo-ventricular Orifice, with Two Small Apertures in the Saeptum Ventriculorum. Tr. of the Path. Soc. of London, 1853-54, V, 64-67. Peacock, T. B., Tr. of the Path. Soc. of London, 1853-54, V, 67- 69. Peacock, T. B., Tr. of the Path. Soc. of London, 1855, VI, 117- 119; I pi. Peacock, T. B., Lectures on Malformations of the Heart, Med. Times and Gaz., London, 1854, VIII, 455, 479, 535, 563, 590. Peacock, T. B., Two Cases of Malformation of the Heart, Tr. of the Path. Soc. London, 1855-56, VII, 80-85. Peacock, T. B., Opening of the Foramen Ovale. Tr. of the Path. Soc. of London, 1858-59, X, 108-110; also Lancet, London, 1859,1,391- Peacock, T. B., Tr. of the Path. Soc. of London, 1859-60, XI, 40- 43, I pi.; also Lancet, London., 1859, II, 485. Peacock, Tr. of the Path. Soc. of London, 1859-60, XI, 68-70; also Lancet, London, i860, 1, 421. Baly, Tr. of the Path. Soc. of London, 1856, X, 90-92. Charnal, Anomalies du coeur et des gros vaisseaux, pression de la circulation pulmonaire et de la circulation generale. Bull. de la soc. anat. de Paris, 1856, XXXI, 435-444. Callender, G. W., Tr. of the Path. Soc. of London, 1857-58, IX, 91-95- 54 THE SURGERY OF THE HEART Schilling, E., New York Jour. 0} Med., 1857, 3 s., Ill, 71-79. Marey, Cas d'anomalie du coeur; obliteration congenitalc de I'artere pulmonaire a son origine, communication des deux ventricules, persistance du canal arteriel, cyanose pendant la vie. Bull, de la Soc. de anat. de Paris, 1857, XXXII, 313-320. Abrahamson, B., Med. Ztg. Russlands, St. Petersburg, 1857, XIV, 225-227. Clark, A., Neiv York Jour. Med., 1857, 3 s., II, 108. Ogle, Sur la persistance du trou de Botal dans le coeur de I'homme adulte a I'etat de sante. Jour, de la physiol de riiomme, Paris, 1859, II, 119-121. BowDiTCH, H. J., Patent Foramen Ovale., Extr. Rec. Boston Soc. for M. Improv., 1859-61-62, IV. 178-180; also Boston Med. and Surg. Jour., 1861, LXIV, 93. Bernard, Note sur un cas de vice de conformation du coeur qui etait divise en deux cavites seulement, etc., Union med., Paris, i860, 2 s., V, 612-616. Meigs, J. F., Proc. oj the Path. Soc. 0} Pkila., 1860-66-67, II> 37- 40. Sacculated pouch just below the Eustachian Valve as an Anatomical Variety, Boston Med. and Surg. Jour., i860 (52) 529- Hervieux, Communication des cavites du coeur entres clles; ab- sence de Tartere pulmonaire, etc. Union Med., Paris, 1861, 2 s., X, 421-427. Nunneley, Tr. of the Path. Soc. of London, 1862, XIII, 42-44. Mallabard, De la perforation interventriculaire du coeur. Strass- burg, 1862. BouiLLAUD, Observation de plusieurs vices congenitaux remis de conformation du coeur, I'absence de la cloison interventric ulaire. Acad, de Med., Paris, 1862-63, XXVIII, 777-782. DuROZiEZ, Exemple de large communication des deux cceurs par le trou de Galien, dit trou de Botal, sans cyanose. Compt. rend, de la Soc. de bioL, 1862, Paris, 1863, 3 s., IV, 105. Cockle, J., Med. Chir. Tr., London, 1863, XLXI, 193, 210; 2 pi. VoisiN, Absence de cloison interventriculaire, insufhsance de I'orifice de I'artere pulmonaire, nombreuses anomalies cardia- CARDIAMORPHIA 55 ques. Bull, de la Soc. d'Anat. de Paris, 1863, XXXVIII, 586- 592. Persistencia del Agujero de Botal sin Produccion de Cianosis y sin Alteraciones de la Circulacion durante la Vida. Espana Med., Madrid, 1863, VIII, 194. Peacock, T. B., Cases of Malformations of the Heart. London, 1864; Malformation of the Heart, Undivided Truncus Arte- riosus, Heart otherwise Double. Ihid., 1864, XV, 89-91. ScHNiTZLER AND RoKiTANSKY, Ueber Persistenz des arteriosen Ganges vom kHnischen Standpunkte. Wien Med. Halle, 1864, V, 108. Peacock, Contraction of the Orifice of the Pulmonary Artery and Deficiency in the Septum Ventriculorum ; Cyanosis. Tr. of the Path Soc. of London, 1862, VIII, 57-59. Peacock, Tr. of the Path. Soc. of London, 1864, XV, 601-62; I pi. Peacock, Contraction of the Infundibular Portion of the Right Ventricle; Deficiency in the Septum of the Ventricles; the Aorta Arising Chiefly from the Right Ventricle; Foramen Ovale Closed. Tr. of the Path. Soc. of London, 1866, XVII, 45- Peacock, Tr. of the Path. Soc. of London, 1869, XX, 61-86; also Peacock, Tr. of the Path. Soc. of London, 1869, XX, 87. Peacock, Tr. of the Path. Soc. of London, 1870, XXI, 78. Peacock, Tr. of the Path. Soc. of London, 1870, XXI, 79. Peacock, Tr. of the Path. Soc. of London, 1870, XXI, 83-86. Power, H., Case of Opening in the Saeptum Ventriculorum, Aorta and Pulmonary Artery given off as One Trunk. Tr. of the Path. Soc. of London, 1865, XVI, 62. Congenital Interven- tricular Opening of the Heart in an i\dult of Robust Health, or Rupture of the Septum two months before Death. Ihid., 1865, LXXII, 209; also Extr. Boston Soc, for Med. Improv., 1862-66, 1867, V, 175-178. Peacock, On Malformations of the Human Heart, etc., with Origi- nal cases and Illustrations. 2 ed., London, 1866. Friedlouski, Fin Fall von Fehlen des x\trium Sinistrum bis auf das linke Herzohr und Einmiindung der Venae pulmonales 56 THE SURGERY OF THE HEART in die Vena anonyma sinistra bei einem Kinde. Med. Jahr., Wien, 1867, XIV, 73-85. Green, T. H., Tr. of the Path. Soc. of London, 1867, XIX, 188. Wagstaffe, W. W., Tr. of the Path. Soc. of London, 1868, XIX, 96-98; I pi. Raynaud, Coeur: anomalies. Nouv. did. de Med. et de chir. prat., Paris, 1868, VIII, 325-342. VuLPiAN, Bull, de la Soc, anat. de Paris, 1868, XLIII, 79-90. Werner, Communication beider Herzkammern durch ein rundes Loch im Septum membranaceum. Med. Cor. Bl. d. Wiirt- tenberg Arztl. Ver., Stutgart, 1869, XXXIX, 209-213. HiCKMANN, Tr. of the Path. Soc. of London, 1869, XX, 93-98. Allis, O. H., Tr. of the Path. Soc. of Phila., 1871-73, 74, IV, 113; also Phila. Med. Times, 1872, II, 294. CoTTiNG, Malformed heart, congenital. Bost. Med. and Surg. Jour.y 1871, VII, 94. Bradley, S. M., Brit. Med. Jour., London, 1873, 1, 33. Fenton, Med. Times and Gaz., London, 1873, H) 338- Balfour, W. G., A Case of Congenital Malformation of the Heart. Lancet, London, 1874, II, 409. GiRAND, Note sur un coeur presentant un cloisonnement anormal du vcntricule droit. Union Med. de la Seine in}., Rouen, 1874, XIII, 129-135. Mo, Presentazione di una rara anomalia del cuore fata alia So- cieta di medicina e chirurgia. Osservatore, Torino, 1874, X, 321-324. Montard-Martin, Retrecissement congenital de I'aorte, athe- rome, hypertrophic du coeur; absence d'une des valvules sig- moides. Bull, de la Soc. anat. de Paris, 1874, XLIX, 737-742. Bernheim, Observations de communication congenitale entre deux ventricules du coeur. Rev. Med. de Vest, Nancy, 1875, IV, 192. Chapman, H. C, Lecture on the Anomalies of the Circulatory Apparatus. Phila. Med. Times, 1875-76, VI, 313-316. 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Jour., St. Peters- burg, 1879, CXXXV, 230-232. Babesin, a. Sziobeli sovengren dillenessegek ezy sajatsagos alak- jarol. Orvosi hetil Budapast, 1879, XXIII, 930, 997, Jarhb. f. Kindish. Leipsic, 1879-80, n. f., XIV, 260-272. 58 THE SURGERY OF THE HEART Allen, H. B., Congenital Malformation of the Heart. Australian Med. Jour., Melbourne, 1879, n. s., I, 2)2)?>' Mackenzie, S., Two Cases of Congenital Malformation of the Heart. Tr. of the Path. Soc. of London, 1879-80, XXXI, 63^ 70; I pi. Charteris, Notes of a Case of Congenital Malformation of the Heart; opening between Aortic Valve and Right Ventricle. Peacock, Tr. of the Path. Soc. of London, 1874, XXV, 62-64. Peacock, Tr. of the Path. Soc. of London, 1876, XXVH, 131-136. Peacock, Tr. of the Path. Soc. of London, 1881, XXXII, 35-38; I pi.; also Lancet, London, 1880, II, 530. Peacock, Large Aperture in the Saeptum of the Auricles, with the Foramen Ovale Closed. Tr. of the Path. Soc. of London, 1878, XXIX, 43-47; I pi- Lees, D. 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Transverse Section of Heart, 4^^ inches from Apex. \ 1 Longitudinal Section of Heart, Din'iding the Right AND Left Heart. (Anatomy of the Heart.) CARDIAMORPHIA 67 Cadet De Gassicourt and Gampert, Rev. mens. d. mal. de Pen}., Paris, 1890, VIII, 49-62. Haddon, W. B., Patent Foramen Ovale in an Adult. Tr. of the Path. Soc. of London, 1890-91, XLII, 65. RoLLESTON, H. D., Communication between the ventricles of the Heart, Congenital. Tr. of the Path. Soc. of London, 1890-91, XLII, 65-67. Carpenter, Microscopic Changes in the Organs found in a case of Cyanosis with Congenital Malformation of the Heart. Si. Thomas's Hospital Rep., 1888-89, London, 1890, n. s., XVIII, 286-296; 1 pi. Shattock, S. G., Tr. of the Path. Soc. of London, 1890-91, XLIII, 280-292; 1 pi. Holt, L. E., Arch, of Peed., 1890, VII, 81-85; i pi. Ettlinger, N. E., Case of Congenital Defect of Heart. Med. Ohozr. Mosk., 1890, XXXIII, 535-543. Audry, C, and Lacroux E., Sur un cas de malformation du coeur. 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C, Tr. of the Coll. of Phys. of Phila., 1896, XVIII, 152-158. Von Berks, A., Ein interessanter Fall von angeborener Anomalie des Herzens. Wien. klin. Rundsch., 1896, X, 497-499. Freyberger, L., Malformed Heart and Great Vessels. Proceed- ings of the Anatomical Soc. of Gr. Brit. & Ireland, 1896, 19. Browiez, On Abnormal Tendinous Threads in the Heart and their Eventual Signification. Medycyna, Warszwa, 1896, XXIV, 621-623. CoHN, I., Ueber doppelte Atrioventrikularostien. Konigsb. i. pr., 1868; I pi. Turner, W., Jour. 0} Anat. and Phys., London, 1895-96, XXX, 568. Przewoski, E., Anomaliae chordae tendinae cordis humani, valvula venae cavae superioris. Pain Towarz Lek., Warszwa, 1896, XCII, 400-422; 3 pi. Packard, F. A., Report of a Case of Imperfect Closure of the Au- ricular and Ventricular Saepta in a man Dead at the Age of Fifty Years from Abscess of the Brain. Med. News, 1896, LXIX, 235-238. Caubet and Baylac, Arch. med. de Toulouse, 1896, II, 329-335. Rhenner, G., Ueber zrwei falle angeborener Herzfehler. Arch, jur path. Anat., etc., Berlin, 1896, CXLVI, 540-546. Boije, O. a., a Great Abnormahty of the Heart in a Child Three Days Old. Finiska Laksallsk handlg., Helsingsfors, 1896, XXXIII, 827-833. Gallois, E., Forme rare de malformation cardiaque cong^nitale. Lyon med., 1896, LXXXIII, 469-476. CARDIAMORnilA /I RoLLESTON, Heart Showing a Muscular Band Pressing between the two jMuscuH Pappillares of the Left Ventricle and Capable of Acting as a Moderator Band. Proc. of the Anat. Soc. of Great Britain and Ireland, London, 1896-97, pp. 21-23. Kalindero and Babes. Un cas de malformation insignificante de la cloison interventriculaire aboutissant a une Idsion mor- telle. Arch, de la Soc. med. de Bucarest, Paris, 1896, I, 481- 485- Sidney, A., Ueber den Abschluss des Sinus coronarus Cordis gegendenrechten vorhof. Anat. Anz., Jena, 1896, XXII, 274, 277. HoBBS, J., Relation de la symphyse cardiaque avec certains aneu- rysmes du coeur. Jour, de med. de Bordeaux, 1896, XXVI, 370- Geronzi, G., Reperto anatomo-patologico ed ossevazioni sul un raro caso di anomaha congenita di cuore. Rijorma med., Napoh, 1896, XII, pt. 3, 629-639. Caille, a., Arch, of Peed., 1896, XIII, 756. Grant, C. G., A Case of Ectocardia. Brit. Med. Jour., London 1896, II, 1639. Moore and Molleson, Notes of a Case of Malformation of the Heart, with Description of Heart. Intercolon. Med. Jour.y Melbourne, 1896, I, 613-615. RoTCH, T. M., An Unusual Form of Congenital Cardiac Mal- formation. Arch, of Pcediat., 1896, XIII, 906. Gaston, J., Polype du coeur gauche avec endocardite auriculaire, insuffisance tricuspide, pleuresie concomitante. Gaz. Med. de Picardie, Amiens, 1897, XV, 122-124. Carpenter, G., Two Cases of Congenital Malformation of the Heart. PcEdiatrics, 1897, III, 149-156. EiSENMENGER, V., Die angeborene Defecte der Kammerscheide- wand des Herzens. Zts. f. klin. Med., Berhn, 1897, XXXIII, 1-28; I pi. Nammack, C. C, Case of Congenital Affection of the Heart in a Woman Thirty-six Years Old. Med. Rec, New York, 1897, LI, 564. 72 THE SURGtRY OF THE HEART ♦ MiRcoucHE AND BoNREAN, Persistence du trou de Botal chez une femme de trente-cinq ans. Bull, de la Soc. Anal, de Paris, 1897, LXXII, 401. Reid, G. a., Note on an Unusually Heavy Heart. Lancet, Lon- don, 1897, I, 1466. Variot, G., Sur I'independance des malformations congenitales du coeur et de la cyanose. Jour, de din. et de therap., Paris, 1897, V, 381-421. Variot, G., Un cas de cyanose avec dilatation de I'artere pulmo- naire, impossibilite du diagnostic clinique des diverses mal- formations cardiaques. Jour, de din. et de therap. inf., Paris, 1897, V, 801-803. Young, J. C., A Case of Defect in the Ventricular Saeptum and Stenosis of the Pulmonary Conus in a Man, Thirty-two Years Old. Medicine, Detroit, 1897, IH, 455-458. Jacobson, Anomalie congenitale du coeur. Bull, de la Soc. Anat. de Paris, 1897, LXXH, 435. Martin, A., Anomalie du coeur. Ibid., 434. Rolleston, H. D,, Pediatrics, 1897, IV, 108-112. Coyon, a.. Affection congenitale du coeur, aorte naissant du ven- tricule, artere pulmonaire naissant du ventricule gauche, per- foration du trou de Botal, persistance du canal arteriel. Jour, de din. de therap. in}., Paris, 1897, V., 505. Coyon, A., Affection congenitale du coeur, transposition des arteres. Bull, de la Soc. Anat. de Paris, 1897, XXL, 519-522. Turner, W., Moderator Band in Left Ventricle and Tricuspid Left Auriculoventricular Valve. Jour. 0} Anat. and Phys., London, 1897, 98, XXXII, 373-376. Fredrick, M., Some Malformations of the Heart and Aorta. Cleveland Med. Gaz., 1897-98, XIII, 151-157. Jameson, S., A Case of Congenital Heart Disease. Australas. Med. Gaz., Sydney, 1897, XVI, 216. Rudolf, R. D., Persistent Foramen Ovale. Canad. Pract., Toronto, 1897, XXII, 879-883. Parsons and Keith, The Frequency of an Opening between the Right and Left Auricles at the Seat of the Foetal Foramen CARDIAMORPIIIA 73 ■s Ovale, Jour, oj Anat. and Phys., London, 1897-8, XXXII, 165-172. Simpson, F. V., Congenital Abnormalities of the Heart in the In- sane. Jour, oj Anat. and Phys., London, 1897-98, XXXII, 679-686. Freyberger, L., Anomalous Truncus Brachiocephalus associated with Aortic Incompetence and Symptoms Simulating Aneur- ysm. Tr. of the Path. Soc. of London, 1897-98, XLIX, 44-46. Damsch, O., Ueber die Bewegungsvorgangen menschlichen Her- zen, Untersuchungen in Anschluss an die Beobachtung des freiliegenden Herzens in einem Fall im angeborenen Sternal- spalte. Leipsic und Wien, 1897. Chiari, H., Ueber Missbildungen im rechten Vorhofe des Herzens. Beit. z. path. Anat., Jena, 1897, XXII, i-io; i pi. Papillon and Suchard, Anomalie de la grande valvule de I'ori- fice mitral. Bull, de la Soc. anat. de Paris, 1897, LXXII, 556. PiTSCHEL, W., Ein Fall von Persistenz des Truncus arteriosus communis. Konigsb., 1897. Kein, G., Communication interventriculaire congenitale sans cyanose, mort part septicemic. Bull, de la Soc. anat. de Paris, 1897, LXXII, 649-652. Cade, A., Un cas de malformation cardiaque congenitale (absence de I'aorte pulmonaire). Lyon mid., 1897, LXXXVI, 155-162. Townsend, C. W., Three Cases of Congenital Heart Disease. Boston Med. and Surg. Jour., 1897, CXXXVII, 493. Warner, F., Congenital Defect of Heart and Other Parts, Prog- nosis and Management. Internal. Clinics, Philadelphia, 1897, III, 157-165; I pi. AussAT, A propos d'un cas de retrecissement congenital de I'artere puhnonaire avec perforation interventriculaire. Jour, de din. et de therap. inf., Paris, 1898, VI, 421-427. RuMMO, G., Vizi cardiaci compento o multipli cardiopatie organ- iche combriate e complicate. Rijorma med., Napoh, 1898. XIV, pt. I, 265. ZiNN, Nachweis einer Anomalie des Herzens durch Rontgen- Strahlen. Deut. med. Woch., 1898, XXIV, vertheil, 41. 74 THE sur(;ery of the heart EiSENMENGER, V., Ursprung der Aorta au5 beiden Ventrickeln beim Defect des Septum Ventriculorum. Wien. klin. Woch., 1898, XI, 25. Brooks, H., Malformation of the Heart. Med. Rec, New York, 1898, LIII, 134. Solomon, L. L., Louisville Med. Monthly, 1898-99, V, 205-207. Della-Rovere, D., Hypoplasie de i linken Herzens mit regelmas- siger Entwicklung des Bulbes aorticus, andere Anomalien der Oeffnungen und Gefasse. Centrbl. }. allg. Path. u. path. anat., Jena, 1898, IX, 209-230. Capitaix, L., Un cas d'inversion du coeur exclusivement. Compt. rend, de la Soc. de bid., Paris, 1898, 10 s., 1104. Humphrey, L., Congenital Malformation of the Heart, System of Med. (AUbut), New York and London, 1898, V, 697-726. Sailer, J., Anomalies of Cardiac Valves. Ihid, 21 1-2 13. Ewald, Cor triloculare biventriculare. Berlin- klin. Woch., 1898, XXXV, 1044. Packard, F. A., Bicuspid Pulmonary Valve. Tr. of the Path. Soc. of Phila., 1898, XVIII, 181-215. Gangitaxo, F., Osservazioni su di un cuore con due semilunari aortiche. Clin. med. ital, Milano, 1898, XXXVII, 234-242. ScoFiELD, A. H., A Case of Congenital Malformation of the Heart. Jour, oj the Am. Med. Assn., 1898, XXX, 1332. Lewis, H. F., Aberrant Tendinous Cords of the Heart. Phila. Med. Jour., 1898, II, 123-126. Cade, A., Un cas de malformation cardiaque congenitale (absence de I'artere pulmonaire). Mem. et compt. rendus de la med. Soc de Lyon (1897), 1898, XXXVII, 129-136. BoNVENUTi, E., Dei vizii congeniti di cuore, stenosi del cono ar- terioso destro, communicazione interventricolare e interauri- colare. Clin. med. Ital., Milano, 1898, XXXVII, 347-366; I ch. Rau, F., Cavemose Angiom in rechtem Herzverhof. Arch. /. path. Anat., etc., Berlin, 1898, CLIII, 22-24; i pl- Rau, F., Offenbleiben des Ductus Botalli. Ibid, 25. Gallaverdin, L., Province med., Lyon, 1898, XII, 391-393. Plate X. View of Right Heart. '^ 1 '''' JB^ ^ % \ ■ ^_ Wf^ iW^' r bwv Incision in Right Ventricular Wall Showing Its Thickness. (Anatomy of the Heart.) CARDIAMORPHTA 75 Sequeira, J. H., Case of Congenital Morbus Cordis with Failure of Physical and Mental Development. Huntcrian Jour., London, 1898, 75. Variot, G., Cyanose liee a une malformation congenitalc du coeur chez un enfant de onze ans et demi, pere mort d'une affection cardiaque rheumatismal, mere vivante atteinte d'un retrecis- sement mitral. Jour, de din. et de therap. in}., Paris, 1898, VI, 783-786. Griffith, T. W., Example of a Large Opening between the Two Auricles of the Heart Unconnected with the Fossa Ovalis. Jour. 0} Anat. and Phys., London, 1898-99, XXXIII, 261. Swan, J. M., Fenestration of the Right Auricle. Proc. of the Path. Soc. of Phila., 1898-99, n. s., II, 71. Smith, F. J., Malformed Heart. Proc. of the Anat. Soc. of Great Britain and Ireland, 1898-99, pp. 5-9. Pepper, W., Multiple Congenital Cardiac Lesions. Univ. Med. Mag., 1898-99, I, 685-687. Eynard, p., Un cas de malformation congenitale du coeur. Mar- seille med., 1899, XXXVI, 111-117. Gerard, G., Pathogenic des malformations du coeur, en par- ticulier de la persistance du canal arteriel. Gaz. d. hop., Paris, 1899, LXXII, 178-198, 208. Gerard, G., A Case of Patent Sseptum Interventriculare, Patent Foramen Ovale, ^nd Congenital Stenosis of the Pulmonary Artery, coupled with an Anomalous Distribution of the Thoracic Veins. Ibid, 35-37. Massart, E., Anomalies cardiaques rares. Clinique Brux., 1899, XIII, 107. RizzARDi, R., I vizii cardiaci acquisiti nei bambini in rapporto alio loro etiologia, sintomatologia, e prognostico. Boll. d. levator, Bologna, 1899. Bonnet, L. M., Anomalies de I'orifice de I'artere pulmonaire. Lyon med., 1900, XCIII, 517-518. Caubet, C, Le retrecissement mitral est une malformation em- bryonnaire. Arch. prov. de med., Paris, 1900, II, 193, 216, 311. 324- ^6 THE SURGERY OF THE HEART Larambergue, Essai sur le retrecissement mitral pur. Paris, Vigot f re res, 1900, No, 511, 100 p. Riss, R., Un cas de malformation cardiaque congenitale. Mar- seille nied., 1900, XXXVII, 402, 407. MoNCOROO, Malformations congenitales multiples du coeur d'ori- gine vraisemblablement heredosyphilitique. Jour, des prac- ticiens, Paris, 1900, XIV, 513-516. Cotton, A. C, Congenital Cardiac Malformation with Endo- carditis and Anuria. Arch. 0} Poediat., 1900, XVII, 731-735; 2 fig. Maccallum, W. G., Congenital Malformation of the Heart as Illustrated by the Pathological Museum of the Johns Hopkins Hospital. Johns Hopkins Bull., 1900, XI, 69-71; 8 fig. Hasenfeld, a., Angeborener combinirter Herzfehler mit Blau- sucht bei einem i8-jahr Madchen. Wien. med. Presse, 1900, XII, 1693-1696. Variot, G., a propos des malformations congenitales du coeur et de leurs signes physiques. Bull., et mem., de la Soc. med. d. hop. de Paris, 1900, 3 s., XVII, 1209, 12 10. Ferranneul, L., Anomahen des Korperbaues bei Kardioptosis. Zentrlhl. /. innere Med., Leipsic, 1900, XXI, 5-9. Starkin, Zur Diagnose der angeborenen Herzfehler. Arch. }. Kinderh., 1900, XXVIII, 201-209. RuNNO, G., Forme rudimentali anomale e^complicate della stenosi mitralica. Rijorma med., Palermo, 1900, I, 350-354. Henrard, G., Un cas d'inversion du coeur. Arch. med. Beiges, Bruxelles, 1900, 4 s., XV, 30-37. Bonner, M., Ueber offenen Ductus arteriosus. Botalli, Inaug. Dissert., Freiburg, 1901. ScHLEGMANN, A., Ucber zwei Falle von angeborenen Defect im Septum Ventriculorum kombinirt mit hochgradiger Stenose der Lungenarterie. Inaug. Dissert., March, 1901. CHAPTER IV ECTOCARDIA Displacement — a putting out of place; applied to various organs. Malpositions — Mains, bad, ponere, to place — the im- proper or abnormal position of any part or organ. Displacement may be congenital or acquired, or it may be due to change with the movements of respiration or bodily posture. Historical (i 797-1 903). — Congenital. The heart may oc- cupy any portion of the thoracic cavity of man. It has, in two cases, been found in the abdominal cavity, the devia- tion from the normal type being greater and more diversified in the congenital displacements. The heart may even protrude through the chest wall, several such cases having been recorded. Abernethy, in 1793, reported an unusual case of transposition of the heart and distribution of the blood-vessels together with a very strange and singular formation of the liver. Lippington (1834) recorded a case of transposition of the heart with complete obliteration of the gall bladder. Lyons (1836) re- ported a case of malposition of the heart with imperforate vagina, and O'Bryan a case of partial ectopia cordis with umbilical hernia. Smith (1808) recorded a case in which the heart was on the right side without transposition of other viscera. Bram- well (1881) reported a rare form of congenital misplacement of the heart in which the organ was situated on the right side of the body, and in which the liver remained on the right 77 78 THE SURGERY OF THE HEART side of the body in its natural position. Robinson (1881) reported a case of transposition of the heart with abnormal and imperfect development, there being only one auricle and one ventricle. Babcock (1884) recorded a most remarkable case of dexiocardia. Augyan (1888) gave an interesting account of a case of dexiocardia with insufficient bicuspid valves. Huchard (1888) and Holt each report a case in which the apex beat was in the abdominal cavity, the heart being there also. Frangois-Franck (1889) mentions a novel case of con- genital cardiac ectopia. Sandhoff (1890) reports a case of congenital dextrocardia and transposition of the thoracic viscera. Abrams (1900) professes to have discovered a new physical sign in dislocation of the heart. He states that gastroectatic dyspnoea and pseudoangina indicate a displaced heart. Droog (1894) reports a case of congenital dextro- cardia with hernia of the lung. Perregaux (1894) records a case of displaced heart in a new-born infant. There was apparent absence of the right lung. It died of suffocation. MacLennan (1896) speaks of a case in which there was dexio- cardia without displacement of other viscera. Gerrard (1896) reports a case of dextrocardia with the apex beat four inches and a half to the right of the ensiform cartilage, with no impulse at its normal position. Pic (1897) reported a case of pleural efifusion in which the differential diagnosis involved congenital dextrocardia. Morgagni recorded a case of ectopia cordis congenita. Barna- do (1897) recorded a case of ectopia cordis with a fissure in the sternum. Oki (1898), of Tokio, gave a unique description of a mis- placed heart, and Duchamp reported a case of dextrocardia with general visceral inversion in which he applied the x ray to determine the diagnosis. Stockton (1897) recorded a case of phrenic paralysis with transposition of the heart. Dalton (1898) reported a case of dextrocardia with left superior ECTOCARDIA 79 vena cava. Michael (1900) mentions a case of dextrocardia complicating chorea. Fitzgerald's (1900) case was one in which the apex beat was below the angle of the right scapula. Murrell, D. E. (1901), in a personal communication, re- ports the case of C. F. Smith, twenty-four years old, five feet ten inches high, with the chest well developed and of even conformation, measuring thirty-nine inches on inspira- tion and thirty-five inches on expiration. The apex beat of the heart was two inches to the left of the right nipple and the same distance below that point, the impact being- most distinct at the lower border of the sixth rib. This condition was discovered several years ago in examining his chest for an attack of pneumonia, at which time he said he had known for some time previous that his heart did not beat where other people's did. There was no effusion then to account for the displacement and no previous history of any trouble about the chest. His health was good and the dextrocardia, no doubt, was congenital. He was a bolt- maker by occupation. Acquired Malpositions. — The position of the heart may be changed suddenly (as by trauma) or the change may be gradual, most frequently the latter. If sudden, it is due to the sudden change in the shape of the chest, or haemorrhage into it, or both. If slowly changed, it may be due to numerous causes, such as aneurysm of the arch, empyema or hypertrophy, di- rect or indirect pressure from the accumulation of hard or soft fluids within the thoracic, mediastinal, or abdominal cav- ity, or tumor growth of the hard or soft tissues entering into the formation of either of these cavities or their contents. A frequent cause in changing the position of the heart is found in curvature of the spine. Stokes (1831) records a case of probable dislocation of the heart from violence. Curran (1862) reports one of malposition of the heart result- ing from collateral disease or visceral derangement; Green- 80 THE SURGERY OF THE HEART ough one in which the heart was displaced to the right side as a result of disease of the right lung. Brackenridge (1880) §ave a clinical lecture on pulmon- ary phthisis with fibroid contraction of the right lung, dis- placement of the heart upward and to the right, angular bending of the aorta, and dilatation of the angle, simulating a considerable aneurysm. Lambert (1880) recorded a case of traumatic cardiac hernia. McSherry (1886) recorded a case of displacement of the heart to the left due to contrac- tion of the lung on that side. Nedwill (1887) records one of extreme displacement of the heart from the left to the right, from purulent efTusion into the left pleura. Kukharski (1888) mentions complete transposition of the heart to the right half of the thorax, following atelectasis of the right lung. Lannelongue (1888) wrote of ectocardia and its cure by autoplasty. Hawkins (1890) mentions a case of displace- ment of the heart to the right side, the other viscera being normal in position. There was pulmonary stenosis with re- gurgitation. McGee reports a case of acquired dextrocardia. Hall (1898) reports one due to lung disease. Satterthwaite (1899) reports one due to lateral curvature of the spine; Wilson, one with functional irregularity due to pleuritic ef- fusion. Barbier (1900) reports a case of dextrocardia re- sulting from pulmonary tuberculosis. Leusser (1902) con- siders movable heart and offers various suggestions for its relief. Lannelongue (1901) reports his observations on a successful operation for ectocardia performec in 1888. Beeson, C. F. (1903), records a case of displacement of the heart due to aneurysm of the descending aorta. Cardiaptosis.— Abrams (A^. Y. Med. Journal, Sept. 5, 1903, p. 484), considers the downward falling of the heart (non- congenital) due to: i, increased size and weight of the heart; 2, aneurysms and new growths that displace the heart down- ward; 3, adhesions pleural and pericardial. ECTOCARDIA 8l BIBLIOGRAPHY Aberxethy, J., Tr. of the Royal Soc, London, 1793, 59-63. Smith, J., A Very Singular Position of the Heart, with the Dis- section. Phila. Museum, 1808, IV, 43-46. Barton, R.R., American Medical Recorder, IV, 1821, 217. Stokes, W., London Med. Gaz., VIII, 1831, 560-563. LiPPiNGTON, H. G., Lond. Med. Gaz., XV, 1834, 228-230. Lyons, P. M., London Med. Gaz., n. s., I, 1836, 514-516. O'Bryan, Tr. of the Med. and Surg. Ass'n., London, VI, 1838, 374-384- Benson, Dublin Med. Press, II, 1839, 114, 116. Croly, H., Dublin Med. Press, IV, 1840, 21. Joy, W. B., System of Practice of Medicine, Philadelphia, 1841, ni, 365, 567. Townsend, R., Cycl. of the Pract. of Med., Philadelphia, 1845, II, 385-391- Webb, A., Tr. of the Med. and Phys. Soc, Calcutta, 1845, IX, pi. I, 272. Saunders, Western Lancet, Cincinnati, VI, 1847, 226. Brown, B., Bost. Med. and Surg. Jour., 1855, LII, 1-17. Jones, S., Tr. of the Path. Soc. of London, VI, 1855, 98-106. Spring, Note sur deux observations de dislocations du coeur. 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Lambert, Lancet, London, 1880, II, 261. Brackenridge, D. T., Lancet, London, 1880, I, 80-117, Krieger, a., Zur Geschichte der congenitalen Dextrocardie iiber einen dies Missbildung vertauschenden Krankheitsfall. Ber- Hn, 1880. Curtis, H., Displaced Heart. Bost. Med. and Surg. Journal, CII, 1880, 466. Wernicke, R., Dextrocardia, situs inversus viscerum. Rev. Med. Quar., Buenos Aires, XVII, 1880-81, 215. SiBSON, F., Reynolds's Syst. of Med., London, 1877, IV, 125-148. Bramwell, B., Edinburgh Med. Jour., XXVTI, 1881-82, 743. Wiltshire, J. G., Maryland Med. Journal. Baltimore, VIII, 1881-82, 319. Robinson, A. R., Bull. 0} the New York Path. Society, I, 1881, 48-50. Pope, C, Lancet, London, 1882, II, 9. Chew, S. C, Tr. of the Med. and Chir. Fac. of Maryland. Bal- timore, 1883, 253-255. Hein, Vitium cordis, situs viscerum inversus gebessert entlassen. Berlin D. K. K. Krankenanstalt Rudolph Stiftung in Wien (1883) 1884, 326. Tarnier, Ectopic cardiaque. Bull, de PA cad. de med., Paris, 1883, XII, 955-957- De Ritis, M., Dello spostemento del cuore a destra. Eco d' Esp., Napoh, 1883, I, 39-45- Marcy, Rapport sur un cas d 'ectopic congenitale du coeur. Bull. de VAcad. de med., Paris, 1883, XII, 1208-1222. ECTOCARDIA 83 Mayerhofer, Dilatation des Herzens. Med.-chir. Centrbl., Wien, 1883, XVIII, 491- Van Zant, C. B., A Case of Congenital Dexiocardia. Lancet- Clinic, XIII, 1884, 158. Charpentier, Ectopic cardiaque thoracique. Bull, de la Soc. med., Paris, XVIII, 1883-84, 1 76-181. Babcock, R. H., Med. News, Philadelphia, XLV, 1884, 452-455. Perna de Salomo, L., Ectopia del Corazon y Exagerada Lentitud del Pulso. Cron Med.-quir. de la Habana, 1885, Vol. XI, 119. Macaldowie, a. M., Displacement of the Heart Occasioned by Traction. Brit. Med. Jour., London, 1886, II, 156. Shershevski, M. M., Importance of Transposition of the Heart. Vratch, St. Petersburgh, 1886, XXVII, 657, 666. Alivia, M., Lo spostamento a destra del cuore e la ipertrofia del ventricolo destro per aderenze pleuriche totali. Gazz. d. osp., Milano, 1886, VII, 554, 563, 57i- Nixon, C. J., Displacement of the Heart. Brit. Med. Jour., Lon- don, 1886, I, 1066. McSherry, Med. and Surg. Reporter, Philadelphia, LIV, 1886, 199 BoxALL, R., Incomplete Pericardial Sac, Escape of Heart into Left Pleural Cavity. Tr. of the Obst. Soc. of London, XXVIII, 1886, 1887, 209. MozHAiKiN, P. A., Sluchal extopia cordis pectoralis, protok Za- said guber zemsk, wrach soveta 1886. Kursk, 1887, IV, 50-63 SussMANN, L., Beitrag zur Casuistik der angeborenen Rechtslag- erung des Herzens (Erlangen). Miinchen, 1887. McPhail, Case of Displacement of the Heart. Glasgow Med. Jour., XXVII, 1887, 454, 457- Schrotter, Ueber angeborene Dextrocardia. Berlin, klin. Woch., XXIV, 1887, 448-450. Nedwill, C, Lancet, London, 1887, I, 68. MojAiKiN, P. A., Protok Zasaid guber zensk vrach soveta Kursk., 1887, IV, 59-63. MossE, Ein Fall von idiopathischer, Brachycardie, Deut. Med. Woch., Leipsic, XXVI, Berlin, 266. 84 THE SURGERY OF THE HEART Kendall, J., Ectopia Cordis. Brit. Med. Jour., London, i^ II, 490. KuKHARSKi, I. G., Kavkazsk Med. Obsh., Tiflis, 1888-89, XXV, 511-523- Lannelongue, Ann. med.-chir. franc, et etrang., Paris, 1888, IV, 101-107. The nature of the rotation which the heart under- goes in acquired dexiocardia as shown by autopsies in two cases, Ihidy 1888, LIII, 288-293. Gruss, a., Ein Fall von Dextrocardie ohne Situs perversus der ubriger Brust-und der Bauchorgane. Wien Med. BL, XI, 1888, 129-135. Michel, J. F., Dextrocardia. Med. Rec, New York, XXXIV, 1888, 479. AuGYAN, B., Riv. veneta di Soc. med. venezia, VIII, 1888, 555-565. HucHARD, H., Bull, et mem. de la Soc. med. des hop. de Paris, V, 1888, 300. RuMPF, Ueber das Wanderherz. Verhandlg. d. Cong, inner e Med., Wiesb., VII, 1888, 221-230. Francois, Compt. rend, de la Soc. de Biol., Paris, 1888, 8 s. V, 765. Chaberly, Dextrocardie. Jour, de med., Bordeaux, XVII, 1888- 89, 16. Pepper, W., Multiple Congenital Cardiac Lesion. Univ. Med. Mag., Philadelphia, 1888-89, 1. 683-687. Rauzier, G., Un cas d'apparente ectopic du coeur (choc cardiaque au niveau du mamelon droit) explique par un emphyseme con- siderable du poumon gauche, un leger epanchement enkyste de la plevre gauche et une dilatation enorme des cavites du coeur. Gaz. hebd. de la Soc. Mont pel., XI, 1889, 493-496. Pick, A., Ueber das bewegliche Herz (Cor mobile). Wien- klin. Woch., II, 1889, 747, 770. Grunfeld, E., Ein fall von Dextrocardie. Prag. med. Woch., XIV, 1889, 2. Francois, Arch, de phys. normale et path., Paris, 1889, 5 s, I, 70-87. Darning, J., A Case of Transposition of the Aorta and Pulmonary Artery with Patent Foramen Ovale, Death at Ten Years of Age. Tr. of the Path. Soc, Philadelphia, 1890, 1891, II, 46-50. I Plate XL Anterior A'iew of Left Heart Showing Incision in Apex. Penetrating Incision of Left A'entricular Wall Showing Its Thickness. (Chapter on Wounds of Heart.) ECTOCARDIA 85 Becker, E., Ueber Dexicardie. Jena, 1891. CiPPRiANi, C, Cuore unicavitario, trasposizioiie polmonale in soggetto destrocardio morto a venti anni. Sperimentale, Firenze, LXVI, 1890, 127-148. Piazza- Martini, Sulla dextrocardia acquisita permanente com- patible colla vita. Sicilia med., Palermo, 1890, II, 554-567. Grunmach, E., Ueber angeborene Dexiocardie verbunden mit Pulmonalstenose und Septumdefection des Herzens ohne Situs Viscerum inversus. Berlin- klin. Woch., XXVII, 1890, 22-25. Sandhop, M., Griefswald, 1890. NiESEL, Ueber einen Fall von Dextrocardia. Deutsch. med, Woch., Leipsic, XVI, 1890, 499, Adie, Misplacement of the Heart. Indian Med. Gaz., Calcutta, XXV, 1890, 117-119. Hawkins, F. H., Tr. of the Clin. Soc. of London, XXIV, 1890-91, 25^253. Graanboom, Ein FaU von Dextrocardie mit Transposition von alien grossen Gefassen. Ztschr. }. klin. Med., Berlin, XVIII, 1890-91, 185-192. EwART AND Bennet, Case of Dexiocardia. Tr. of the Med. Soc. of London, XIV, 1890-91, 438. Arnaud, H., Compt. rend, de la Soc. de biol. Paris, 1891, 9 s., Ill, 4-8. Inches, P. R., Maritime Med. News. Hahfax, III, 1891, 63. ScHOTT, Deut. med. Ztg. Berhn, XII, 1891, 409-413. Varsi, T., Ann. de VAsist. Pub., Buenos Aires, II, 1891, 1892, 46-58; I pi. Tauszk and Vas Adatok, a sziv helyzetvaltozasahoz. Orvosi hetil. Budapest, 1891, XXXV, 14, 28, 43, 67. ScHOTT, Zur Kasuistik der kongenitalen Dextrocardie. Veroj- jentl. d. Hufeland. Gesellsch. in Berlin, Balneol-Gesellsch., XIII, 1 89 1, 3c^45. Salaghi, S. S., Exocardie, appareil pour le traitement mecanique de diverses maladies, methode employee. Bologne, 1891. Berwald, Ein Fall von Dextrocardie. Berlin, klin. 86 THE SURGERY OF THE HEART Heicmann, Ueber eine Anomalie der Lage des Herzens, Berl. klin. Woch., XXIX, 1892, 188. Bard, L., Refoulement du cceur a droite et extrocardie congenitale. Lyon med., LXXI, 1892, 583; 1893, LXXII, 15. Heyse, Ein Fall von hochgradiger Verlagerung des Herzens nach der linken Seite. Deut. Med. Woch., Leipsic und Berlin, XIX, 1893, 1064-1068. Droog, E. a. M., Nederl. Tijdschr. Geneesk. Amst., 1894, 2 R., XXX, pt. I, 872-80. Perregaux, G., Bull, de la Soc. anal, de Paris, LXIX, 1894, 968- 971. Kreisch, E., Ein Fall von hochgradiger Verlagerung des Herzens in die rechte Brustseite. Bonn, 1894. Storen, E., Et tifaelde af medfedt dextrokardi. Norsk. Mag. f. Laegevidensk., Christiania, 1894, 4 R X, 93-97. LiviERATO, P. E., Spostamento paradosso del cuore. Arch. ital. di din. med., Milano, XXXIII, 1894, 38-41. GoRYANSKi, G. I., Sluchal situs cordis transpositus Bolnitsch. Gaz. Botkina, St. Petersburg, 1895, VI, 369, 374. Imotana, E., Zur jungsten Demonstration eines Falles von Ectopia Cordis. Wien. med. BL, XVII, 1894, 191. ScHMiD-MoNNARD, Vorstellung eines Falles von Dextrocardie ohne Situs Viscerum inversus. Munch, med. Woch., XLI, 1894, 584. Spaink, p. F., Een Gaval van Dextrocardie. Geneesk. Courant, Tiel, LXVIII, 1894, No. 25. Aroz-Afaro, G., Un caso de esclerosis pulmonar con dextro- cardia. Rev. de la Soc. Med. Argent., Buenos Aires, 1895, IV, 73-80. Passelt, Deutsch. Arch. }. klin. Med., Oct. 25, 1895. Campbell, G. G., Cardiodextria. Montreal Med. Jour., XXIV, 1895-96, 515. Von Nadeskay, Anatom. Anz., Jena, XII, 1896, 269-272. Maclennan, W., Brit. Med. Jour., London, 1896, II, 1314. Bari, a. E., Blntsch. Gaz. Botkina, St. Petersburg, VII, 1896, 721-758. ECTOCARDIA Sj SoBiERAjczYK, A., Zur Casuistik der Dextrocardie nebst Be- schreibung eines diesbeziiglichen neuen Falls. Berlin, 1896. Steiner, T., Ueber angcborcne und erworbene Dextrocardie in- folge rechtsseitiger Schrumpfungspleuritis. Berlin, 1896. Grant, C. G., A Case of Extocardia. Brit. Med. Jour., London, 1896, II, 1639. Haines, Brooklyn Medical Journal, March, 1896. Fernet, Un cas d'ectopie cardiaque (dextrocardie) sans inversion des visceres, interpretation pathogenique. Bull, et mem. de la Soc. med. d. hop. de Paris, XIII, 1896, 873-875. Gerrard, p. N., a Case of Dextrocardia. Lancet, London, 1896, I, 1060. Petit, L. H., Ectopic cardiaque a droite consecutive a une pleu- resie droite. Bull, et mem. de la Soc. med. d. hop de Paris, XIV, 1897, 989-994. Petit et Ravant, Dextrocardie isolee d'origine congenitale. Ibid, 195-200. Benedikt, M., Beobachtung und Betrachtungen aus dem Ront- gen Kabinette der Verdrehungen des Herzens. Wien. med. Woch., XLVII, 1897, 369. Pic, a., Province med., Lyon, XI, 1897, 30S. Vehsemeyer, Ein Fall von congenitaler Dexiocardie, zugleich ein Beitrag zur Verwerthung der Rontgenstrahlen der innern Medicin. Deut. med. Woch., Leipsic, XXIII, 1897, 180; i pi. MuGGiA, A., Morgagni, Milano, XXXIX, 1897, 202-210. Holt, L. E., Med. News, LXXI, 1897, 769. Pascheles and Paltauf, Ein Fall von Dextrocardie. Wien. klin. Rundschau, XI, 1897, 473. Revello, R., Spostamenti del cuore. Pammatone, Genova, 1897, I, No. 3, 68-76. AucHE ET BouYER, Dextrocardie pure sans inversion generale. Jour, de med. de Bordeaux, XXVII, 1897, 413-415. CocHEZ, A., L'ectopie du coeur a droite consecutive a la pleuresie droite. Gaz. d. hop., Paris, LXX, 1897, 514-542. Barnado, G. F., Jour, of Anat. and Phys., London, XXXII, 1897-98, 325-333- 88 THE SURGERY OF THE HEART Capitan, L., Un cas d'inversion du coeur exclusivemcnt. Compt. rend, de la Soc. de bioL, Paris, V, 1898, 1104. Caporali, R., Sulla dislocazione funzionale del cuore. N. Riv. din. terap., Napoli, I, 1898, 400-408. McGee, J. H., Intercol. Med. Jour., Melbourne, III, 1898, 662- 664. Hall, J. N., Med. Fortnightly, St. Louis, XIII, 1898. Oki, K., Tokyo Iji-Shinshi, 1898, 2126-2128. Green and Rothrock, A Case of Concentric Displacement of the Heart to the Right presenting some Unusual Features. Phila. Med. Jour., 1, 1898, 563. DucHAMP, Loire med., St. Etienne, XVII, 1898, 87-91. UsoFF, P., Rare Case of Displaced Heart. Med. Obozr. ,Mosk., XLIX, 1898, 546-550. Stockton, C. G., Tr. of the M. Assn. of Central N. Y., 1897, Buffalo, 1898, 134. Berend, M., a Case of Congenital Dextrocardia. Gyermekgyo- gasazt, Budapest, 1898, 16. RuMMO, G., Sulla cardioptose primo abbozzo anatomo-clinico. Arch, di med. int., Palermo, 1898, I, 161-183. Westermayer, E., Untersuchungen iiber die passiven Verlager- ungen des Herzens. Festch z. Eroffn. d. n. Krankenh. d. Stadt Numb., 1898, 471-481. Dalton, N., Tr. of the Path. Soc of London, 1898-99, I, 41. Ferrannini, a., Le dislocazioni del cuore studiate con un metodo cardiotopo-megetometrico. Lavori d. cong. di med. int., 1898; Roma, 1899, IX, 358-364. Determann, H., Demonstration der Verschiebung des Herzens bei Lagerveranderungen des Herzens mittels des Rontgenver- fahrens. Verhandlimg d. Cong. j. innere. Med., Wiesb., 1899, XVII, 606-610; I pi. Satterthwaite, T. E., N. Y. Med. Jour., LXX, 1899, 469- 475- Leo, H., Ueber einen Fall von Dexiocardie. Jahrb. }. Kinderh., Leipsic, 1899, n. F., i, 427-430. Lepine, R., Dextrocardie causee par la retraction du poumon droit ECTOCARDIA 89 consecutive a une peribronchite syphilitique avec adherences pleurales. Bull, et mem. de la Soc.d. hop. de Paris, 1899, 3 s., XM, 497-499- Fraxcois-Franck, Nouvelles recherches sur un cas d'ectopie cardiaque (ectocardie) pour servir a I'etude du pouls jugu- laire normal et d'une variete de bruit de galop. Arch, de phys. norm, et path., Paris, 1899, I, 70-87. Bernheim, S., Les ectopies cardiaques. Independ. med., Paris, V, 1899, 313-315. G.AJRXiER, Un cas de dextrocardia avec autopsie. Presse mid., Paris, II, 1S99, 15-18; Le anomaHe antropologiche nei car- dioptosci. Arch, ital di med. int., Palermo, II, 1899, x, 1^$- 156. MuLLiCK, S. K., Case of Dextrocardia, Tr. of the Med. Soc. of London, XXIII, 1899-1900, 345. Fremmer, J., Seltene Falle in der Privatpraxis, 2 Falle von Dextro- cardie. Pest. Med.-chir., Presse, Budapest, 'KXXVl, 1900, 985-989. Crispino, M., Riforma med., Palermo, III, 1900, 436. Lo^VTixTHAL, H., Ztsch. }. klin. Med., XLI, 1900, 130-136. Wilson, F. C, Memphis Med. Monthly, XX, 1900, 458-468. Bailbeer, H., Bull, et mem. de la Soc. med. des hop. de Paris, 1900, 3 s., X\'II, 187-191. ScHMELiNSKY, Fall von Dextrocardie mit Persistenz des Ductus arteriosus Botalli. Deut. med. Woch., Leipsic, XX\'I, 1900, Berlin, 194. Thomas, H. M., Demonstration of a Case of Dextrocardia. Chi- cago Med. Recorder, XIX, 1900, 318. Michael, May, Woman's Med. Jour., Toledo, IX, 1900, 4-7. Kow"EXTHAL, Die Beweglichkeit des Herzens bei Lagen^erhan- derungen des Korpers (Cardioptose). Ztschr. f. klin. Med., Berlin, XI, 1900, 24-58. Henilard, C, Un cas d'in version du coeur. Arch. med. beiges, Brux., XV, 1900, 30-37. Fitzgerald, G. C, Brit. Med. Jour., London, 1900, II, 664. Andre, Dextrocardie acquise. Lyon med., XCV, 1900, 417. 90 THE SURGERY OF THE HEART Chapman, H. G., A Case of Dextrocardia. Intercolon. Med. Jour., Melbourne, V, 1900, 309. Crisping, M., Un caso di destrocardia congenita pura. Rijorma med., Palermo, XVI, 1900, pts. 436, 447, 459. Abrams, Med. Record, New York, LVIII, 372-374. Plessi, D. R., Note vole spostamento del cuore de essudato pleu- rice. Gazz. d. osp., Milano, XXII, 1901, 117-119. Weinberger, M., Seltener Fall von Verlagerung des Herzens in die rechte Brusthohle. Wien. klin. Woch., XIV, 1901, 129. Monks, E. H., Brit. Med. Jour., London, 1901, I, 514. Chapgst-Prevost, De I'inversion du cceur chez un des sujets composants un monstre double autositaire vivant de la famille des pages. Compt. rend, de VAcad. d. sc, Paris, CXXXII, 1901, 223-225. MuRRELL, D. G., Railway Surg., Dec, 1901, p. 212. Leusser, Munchener med. Woch, July i, 1902; also American Medicine, Oct. 25, 1902. Lannelgngue, Compt. rend, de VAcad. d. sc, Paris, CXXXII, 1901, 225. Beeson, C. F., American Medicine, 1903, p. 379. CHAPTER V GUNSHOT, LACERATED, AND INCISED WOUNDS Wounds of the heart are of many characters and degrees. Before the use of firearms, daggers, spears, and arrows were most common, but since the introduction of firearms it is probable that injuries of the heart are more frequently due to their use. Historical (i 552-1903). — Pare, in 1552, was one of the first to refer to the statement that heart wounds must result in instant death. He saw a dueHst run two hundred paces before falling with a sword wound in his heart large enough to admit the finger. In the meantime he fought his antag- onist in a most vicious manner. Senac, in 1749, attributed the sudden death to profuse bleeding, while Morgagni thought it due to obstruction of the circulation dependent upon the distention of the peri- cardium from bleeding. The latter author reports the case of Valsalva, in which death occurred on the eighth day fol- lowing a wound of the right ventricle. Aprilis wrote concerning a case of sword wound of the right auricle, resulting in death five days after. (This report is in the first medical journal ever published, 1680, Obs. X, a copy of which is now in possession of the Surgeon-General of the United States Army.) In the case reported by Courtial (1705), in which there was a wound of the left ventricle, the patient walked five hundred paces and lived five hours. Chastanet (1783) collected many cases of gunshot wounds of the heart from the records of Bonetus, Morgagni, and others, 91 92 THE SURGERY OF THE HEART and recorded five interesting cases of his own. Lerouge (1792) reports the case of a soldier who resumed his voca- tion on the ninth day after receiving a stab in the right auricle, and died suddenly on the eleventh day at a cab- aret. The case of Durande (1798), in which there was a sword wound of the right ventricle, did not terminate fatally until the end of the fifteenth day. This patient lived longer than the usual time after the infliction of such a w^ound. If life is prolonged to this extent recovery usually ensues. In Babington's case of the same year (1798) the patient lived but nine hours after having received a bayonet thrust through the entire heart. In the case of Frisi the patient lived ten days after having received a wound of the left ventricle. Fournier (1834) reports the case of a soldier who received a gunshot wound in the breast followed by profuse haemor- rhage. He was thought to be dead; however, he rallied and in three months recovered, dying three years later, when the ball was found buried in the apex of the heart. One of the most curious cases on record is that of Holmes (1845), ^vho reports an accident in which there was a gun- shot wound of the heart without perforation of the peri- cardium. This ball entered from above, passing through the base of the heart, clearing the pericardial attachments. Lav- ender (1851) mentions a case of recovery following a pene- trating wound of the right ventricle. Carnochan (1855) re- ports a case of gunshot wound of the heart in which life was protracted for eleven days. The bullet was found encysted in the heart's substance. An interesting complication of gunshot wounds is re- ported by Prichard (1855), in which a ball, after having en- tered the chest, passed through the heart and stomach. Purple (1855) reports twelve cases of gunshot injuries of the heart in which the patients survived from forty-four hours to six years. GUNSHOT, LACERATED, AND INCISED WOUNDS 93 Grant (1857) reports a case of gunshot wound in which the ball after entering the chest, passed through the heart and stomach. In the case of Bullock (1858) the patient lived four days and eighteen hours with a bullet in the left ventricle. Andrew (i860) showed a case coming under his observation in which a fish bone, after having lodged in the oesophagus and per- forated it and the diaphragm, entered the heart. Croly (1864) reports the finding of a musket ball in the peri- cardium. The reports of heart injuries in the American civil war, 1861-65, are very indefinite and unsatisfactory, so much so that they will be given but passing mention. No attempt, it seems, was made in any case to adopt surgical measures. U. S. A. Report, 1865 to 1871, No. 3, S. G. O. P. 91, Medical Museum, U. S. A., Spec, 1,837, shows a gunshot injury to the left ventricle and right auricle. The patient survived seventy-five minutes. Medical Museum, U. S. A., Spec. 2,639, shows a gunshot injury, an anteroposterior perforation of the left ventricle near the sseptum, with instant death. Medical Museum, U. S. A., Spec. 5,688, shows a laceration of the right ventricle by a pistol ball, with instant death. Medical Museum, U. S. A., Spec. 5929, shows an oblique perforation of the anterior wall of the left ventricle by a small Derringer ball; cavity not open. The patient, a suicide, lived twenty-seven minutes. Medical Museum, U. S. A., Spec. 5,949, shows a pistol shot through the right ventricle. The patient lived fifteen minutes. Medical Museum, U. S. A., Sec. I, Spec. 1,052, shows a gunshot wound of the left ventricle. Medical Museum, U. S. A., Spec. 5,648, shows a gunshot wound of the right ventricle and auricle causing in- stant death. Medical Museum, U. S. A., Sec. i, Spec. 4,870, shows a stab in the apex of the right ventricle by a jack knife. The wounded man ran thirty yards and Hved twelve minutes. Medical Museum, U. S. A., Sec. i, Spec. 504, shows a mus- 94 THE SURGERY OF THE HEART ket ball imbedded between the innominate artery and the descending aorta. Hart reports a wound of the heart of a deer with recov- ery. Robert mentions the case of a man who ran sixty yards and lived one hour after having been shot through both lungs and the right auricle of the heart. Dudley (1871) re- cords the case of a man who lived four days with a pistol ball in his heart. Ford (1875) speaks of a case of recovery from buckshot wound of the heart. Vite (1876) in his min- utes speaks of the tenacity of life of a person who lived four days with a knife wound penetrating the chest into the peri- cardial sac and passing through the left ventricle of the heart into the opposite wall. Among the cases of recovery from gunshot wounds of the heart is that of Mellichamp (1876). Then a similar case resulting in recovery is reported by Heil (1878). This patient lived twelve months after having received a stab wound penetrating the aorta. West (1878), of Birmingham, reports a case in which a man lived four years and a half. The autopsy revealed a linear scar, half an inch long, in the anterior part of the right ventricle. Gibney (1878) reports a case of a pistol ball passing through the right ventricle, ssep- tum, and aorta. Holly, during the same year, reports a case of pistol shot through the right ventricle, sceptum, and aorta. There was apparent recovery at the end of the fourteenth day, but sudden death occurred on the fifty-fifth day. The autopsy revealed the ball lying in the left ventricle. In the case of Boileau (1879) there was a penetrating wound of the heart, involving the transfixion of both ven- tricles, but death did not ensue for several minutes. Dun- ham's patient (1879), ^fter having received a bayonet wound implicating both ventricles, the saeptum, and the auricle, walked several yards after the injury and died at the end of forty-six hours. In another case death did not result until the end of fifty-four days. Death resulted from rupture Plate XIT. Showing Skewer Penetrating the Two Ventricles FROM Right to Left. A Direct Penetrating Knife Wound of Left Ven- tricular Wall. (Cliaptcr on Wounds of Heart.) GUNSHOT, LACERATED, AND INCISED WOUNDS 95 at the point of lodgement in the case of Robbins, on the eleventh day. Say re (1881) reports a recovery from a lacera- tion of the pericardium and contusion of the heart. Simmons (1882) reports a case in which a pistol ball, after having entered the heart, had fallen into the inferior cava. Randall (1882) reports the case of a negro boy who died sixty-seven days after having received a gunshot wound of the chest, from overeating. There were no signs of heart wound. The autopsy revealed three shot in the base of the ventricle and two in the auricle. The wounds in the wall of the organ were all firmly healed. In the case of the author (1882) there were numerous perforations of the chest by buckshot, one having passed through both auricular walls and the left lung, one through both ventricular walls and the left lung, and one through the liver and the abdominal aorta, all from right to left, with all these wounds the patient walked ten paces. Ward (1883) mentions a wound of the chest. The ball was found lodged beneath the two layers of the pericardium. There was laceration of the wall of the right ventricle and of a branch of the anterior coronary artery, causing fatal haemor- rhage into the pericardial sac. " I have in my possession the heart of a man, named John Kelly, containing a round ball which lies encysted in the apex of the right ventricle and which was received twenty years before his death. There is conclusive evidence, how- ever, that during the first five years it lay near the right internal jugular vein and that, having at length made its way through the coats of this vein, it dropped into the ven- tricle and finally became imbedded in the wall? of the heart at its apex. It remained in the heart, therefore, fifteen years, and was not then the immediate cause of death." (Hamilton, " Principles and Practice of Surgery," 1886, page 90.) Kravkofif (1887) reports a wound of the left ventricle with recovery. Peebles (1892) reports a pistol wound of the heart 96 THE SURGERY OF THE HEART with recovery. Bell (1894) cites a case of recovery following a puncture of the cardiac wall without suture after the clots had been removed from the pericardium by incision. Sloan (1896) speaks of a case in which paracentesis was undertaken to relieve pericardial effusion, and the right ventri- cle was penetrated and 300 grammes of liquid blood were re- moved. There was rapid improvement for twenty-four hours, slower after that until recovery. In the case of Nelson ( 1896), who was shot, the x ray showed the ball in the heart moving with each pulsation. Spencer and Tippet ( 1896) report a case of punctured wound of the right ventricle of the heart through the second intercostal space, with severe primary and secondary haemorrhages. The wound healed and the patient died of disease. The autopsy revealed the location of the wound. Fisher (1896) shows, in a case he reports, that a rupture of the right ventricle of the heart may result from a blow in the epigastric region. That rupture of cicatricial tissues of the heart may occur is shown in the case of a soldier (a Michigan sharpshooter) who received a bullet wound in the heart at Spottsylvania, Va. He died suddenly, two years later, in such a way. WilHams (1897) reports a stab wound of the heart and pericardium. Suture of the pericardium was performed, with recovery. The patient died three years afterward. Hennen states that a case came under his observation in which a bayonet had been thrust through the colon, stom- ach, diaphragm, lung, and right ventricle, and the man lived nine hours; while in the case of Jackson the patient lived three hours and a half and made depositions to the name of his assassin, after having received two shot wounds in the chest, one passing through the right auricle. Diemerbrock states that a patient walked sixty paces and lived ten days after having received a wound of the right ventricle. Needle zcounds of the heart are quite common. Among GUNSHOT, LACERATED, ANt) INCISED WOUNDS 9/^ those reporting such accidents are Peck (1852), and Pridborn (1856), also Wright (1869). Thomas (1887) reports a case of suicide with a needle, while Thompson (1888) reports one with a pin. Peabody during the same year (1888) found a pin imbedded in the heart of a cadaver. Meacham (1899) also found a needle in the heart upon autopsy. A Sardinian prince met instant death from the puncture of the right ventricle by a gold needle in the hands of his wife. Paget (1897) reports the case of a man, aged thirty-one, who, while in a struggle, received a needle two inches long in the cardiac region. He had pain on the following day, and worked nine days with continuous pain from the nipple to the axilla and down the inner side of the arm to the elbow. An operation exposed the eye of the needle, which moved with each pulsation of the heart. The needle was withdrawn and recovery ensued. In the case of a girl eleven years old, a knitting needle entered the chest, breaking. An operation found it penetrating the heart. The removal was followed by recovery. Callender's patient ( 1897), in attempting to com- mit suicide, drove a needle into the heart. Indications were those of a disturbance by a foreign body. By an operation the pleura was opened, as was the pericardium also ; a gauze sponge was lost in the pleural cavity and was not recovered. The needle head was brought to view, but by strong motion of the heart had been thrown completely into the ventricle and was upright. Pneumothorax occurred six days later. The patient left the hospital in four weeks in perfect health. Among those to compile tables concerning heart wounds was Purple (1855), who reported forty-two cases that were immediately fatal. Twelve of these were due to gunshot. Otis reports twenty-one cases of injuries of the heart in the United States Army, 1865- 1870. Eighteen were gunshot, two incised, and one an arrow puncture. Holmes and Fisher (1881) report a series of 452 wounds of the heart, with 104 98 THE SURGERY OF THE HEART immediate deaths, 219 not immediate, 72 recoveries, and 57 uncertain as to time of death; 123 right ventricle, loi left ventricle, 26 both ventricles, 28 right auricle, 13 left auricle, 7 saeptum ventriculorum, 17 apex, 2 base, 16 whole heart, 4 right heart, 5 left heart, 2 coronary artery, 57 uncertain, and 51 pericardium. He also reports a series of cases of foreign bodies in the heart, such as needles. One entered through the sternum, eight by the oesophagus, thirty by the thorax, and eight by an uncertain route. Fisher enumerates 452 cases, of which 44, with 10 re- coveries, were punctured wounds; 260, with 43 recoveries, were punctured incised wounds; 72, with 12 recoveries, were gunshot wounds; and 76, with 10 recoveries, were con- tusions and traumatic rupture. Olliver and Sanson state that, out of twenty-nine cases of penetrating wounds of the heart, only two proved fatal in forty-eight hours. In the others death took place in from four to seventy-eight days after the wound. Hill records a case in which he extracted a needle that had been forced through the skin into the heart. Fouck and Pramm (1901) report a case of suicide in which a man stabbed himself in the left thorax with a long knife, the weapon pene- trating the pericardium and entering the left ventricle, after which he drew out the knife and laid it on a table near by. The weapon was apparently perfectly clean, but microchem- ical examination of a tiny rust fleck on the blade revealed the presence of hsemin crystals. Roswell Park (1902), in attempting to remove what he supposed to be pericardial fluid with an aspirating needle, removed pus from an abscess cavity in the wall of the heart. (See Chapter on Abscess of the Heart.) GUNSHOT, LACERATED, AND INCISED WOUNDS 99 BIBLIOGRAPHY Pare, 1552, Lib. VIII, C 32. TiMAEUS, Cases Med. Prax. Lcipsic, 1677, Lib. VI (Obs. 38), Subitoque concidens illico Mort. U U S est. Aprilis, 1680 (Obs. X). In possession Surg. General U. S. A. CouRTiAL, Nouv. Obs. Anat. Sur les cas 1705, p. 138. Senac, Traite de la structure du coeur. Paris, 1749, t. II, p. 371. MoRGAGNi (1. c. ep. 67), Valsalva case reported by Morgagni. Opera omnia, t. II, Epist. 53, Ast. 4, Patavii, 1765. Chastanet, Jour, de Med. Militaire, Paris, 1783, t. II, p. 377. Lerouge (Saviards Recueil d'obser. de chir., 1792, obs. 113.) Durance, Memoires sur I'abus de I'ensevelissement des morts. Strasburg, 1798. Babington, W., Med. Rec, Prival, Med. Assn., London, 1798, 59-69- Velpeau, Man who died of pneumonia, had knife wound many years before. Marked cicatrix in right ventricle and large hole in corresponding region of pericardium. Fuge, J. H., Edin. Med. and Phys. Jour., 1818, XIV, 129-132. Sanson, Plaies du coeur. These 1827, p. 16, enumerates the more important cases cited by his predecessors. Stevens, A. H., Account of a remarkable case of injury of the heart. New York Med. and Phys. Jour., 1826; V, 314-16. Randall, L., Report of a case of gunshot wound of the lungs and heart with the appearances after death. West. Med. and Phys. Jour., Cincinnati, O., 1828-1829, II, 329-333. CoxE, J. R., Some observations on wounds of the heart. Am. Jour. 0} the Med. Sc, Philadelphia, 1829, IV, 307, 314. HuRD, Perforation of the heart. London Med. Gaz., 1832, XI, 318-320. Priou (Mem. sur les plaies pen^trantes de la poitrine in Mem. de VAcad. Roy. de Med., Paris, 1833, t. II, 426), speaks of the instant death of an armorer from two pistol wounds of the heart. lOO THE SURGERY OF THE HEART Allinier (d'Angers) records, Hist, de Med., 1834, t. VIII, 54 cases of heart wounds. Frisi, Filiatro Sibezio, 1834, p. 37. FouRNiER, Dictionnaire de Medecine, 1834. Wallace, W., Wounds of the heart. Lancet, London, 1834, II, 140, 41, 45- Fris, Wound of the heart in which the patient survived ten days. London Med. and Surg. Jour., 1835, VI, 171. O'Connor, Remarkable case of punctured wound of the heart, followed by recovery. London Med. Gaz., 1835-36, XVII, 82. Simmons, R. P., Case of gunshot wound of the heart. West. Jour. 0} the Med. and Phys. Sc, Cincinnati, 1836, IX, 382-388. Lees, C, An essay on wounds of the heart. Dubhn Jour. 0} the Med. Sc, 1837, XI, 169-180. Villian, J. C, Observations in physiology and pathological anat- omy, collected to serve as a memoir upon wounds of the heart. (Transl. by H. H. Goodeye.) Quart. Jour. 0} the Calcutta Med. and Phys. Soc, 1838, II, 7-17. Panaroli (Intralogismorune sen Med. Obser. pentacastae quin- que, Roma, 1652, Pent V, Obs. 45), reports a case of wound of the ventricle, which resulted in death five days later. A similar case has been reported by Jobert. Arch. Gen. de Med., 1839, p. 209. JosLiN, B. F., Wound of the right ventricle of the heart made by a carving knife; death in about ten minutes. New York Lancet, 1842, I, 331. Baird, W., Wound of the left ventricle of the heart. London and Edinburgh Month. Jour, of the Med. Sc, 1843, HI* 275-292. Jameson (A surgical wound of the heart). Dublin Med. Press. 1844, XI, 310-312. Holmes, F. A., Brit. Am. Jour., Montreal, 1845-46, I, 227. Richards, G. W., Wound of the heart. Boston Med. and Surg. Jour., 1846-47, XXXV, 336. Alexander, W. F., Death following a wound of the heart after seventy-eight hours. Am. Jour. 0} the Med. Sc, Philadelphia 1847, ^- S-, XIII, 245. GUNSHOT, LACERATED, AND INCISED WOUNDS lOI Drew, J., Death from wound of the heart. Lancet, London, 1849, II, 69. BowEN, W. S., Case of wound of the heart; patient Hved ten days. New York Med. Jour., 1849, II^) 201-203. Trugies, J. W. H., A case of wound of the left ventricle, patient survived five days. Am. Jour, of the Med. Sc, Philadelphia, 1850, n. s., XX, 99-102. CooTE, H., Wounds of the heart. Med. Times, London, 1850, n. s., I, 119. Dawson, W. W., Gunshot wound of the heart. West. Lancet, Cincinnati, 1851, XII, 14. Renaud, F., Case of incised wound of the right ventricle of the heart. London Med. Gazette, 1851, n. s., XIII, 797. Lavender, C. E., Proc. M. Ass. Alabama, Mobile, 1851, 104, 108. Hopkins, R. C, Gunshot wound of the heart; death two weeks after the accident. Ohio Med. and Surg. Jour., Columbus. i852-53» V, 210. Peck, F., Case of wound of the heart by a needle. Prov. Med. and Surg. Jour., London, 1852, 336. Clark, H. G., Wound of the heart. Am. Jour, of the Med. Sc, Philadelphia, 1853, n. s., XXVI, 85. Carnochan, J. M., Am. Med. Month., New York, 1855, III, 272- 277; also reprint. Finnell, Wound of the heart. New Jersey Med. Reporter, Bur- lington, 1855, VIII, 471. Prichard, a.. Association Med. Jour., London, 1855, II, 1085. Purple, Samuel, New York Med. Journal, May (?), 1855. Douglas, J. H., Wounds of the heart and pericardium. New Orleans Med. News, Hasp. Gaz., 1855-56, II, 1 19-127. Pridborn, T. L., Entrance of a needle into the chest. Probable puncture of the heart. Assoc. Med. Jour., London, 1856, II, 1078. Grant, J, H., Charleston Med. Jour., 1857, XII, 303-306. Jamain (Plaies du coeur. These de concours pour I'agregation, Paris, 1857, 8 V, p. 100) has analyzed 121 cases. Bennett, A specimen of a heart from a stout, healthy negro who I02 THE SURGERY OF THE HEART had received a stab. Atn. Med. Month., New York, 1857, VII, 121. Bulloch, W. G., Savannah Jour. Med., 1858-59, I, 295-298. Fraser, J. T., Case of gunshot wound of the heart in which the patient survived three hours and a half. Lancet, London, 1859, II, 507. Hodge, H., Wound of the left ventricle; death in 36 hours. Proc. Path. Soc, Philadelphia, 1857-60, I, 259. Andrew, Lancet, London, i860, II, 186. Helwig (Obser. Medico-phys. Augsburg, i860, Obs. 68) de- scribes sudden deaths from heart wounds. Adams, R., Account of a case in which the left ventricle of the heart was punctured through and through by a gunshot wound, with a few observations on small wounds penetrating the pericardium and inflicting injury on the heart or its vessels. Ditblin Med. Press, 1861, XVI, 227-230. LiTTLE^vooD, Wound of the heart by a bayonet; autopsy. Med. Times and Gaz., London, 1863, II. Walter, A. G., A case of bullet wound through the lung and heart. Med. and Surg. Reporter, Philadelphia, 1863, X, 6-8. Otis, Surg. History, U. S. A., Vol. I, p. 530. Croly, H. G., Dublin Med. Press, 1864, LI, 630. Workman, Perforation of the heart. Brit. Med. Jour., London, 1864, II, 574. Helm, W. H., Penetrating wound of the Heart. Med. and Surg. Reporter, Philadelphia, XIII, 1865, 85. BoMAN, W. E., Gunshot wound through the heart. Chicago Med. Jour., XXII, 1865, 199-303. Baulware, J. R., Carbonaceous Lungs; Wounds of the Heart. Tr. Med. Soc, New York, Albany, 1866, 31. Fischer, G., Langenbeck's Archiv, IX, 1867, 591. Smith, S., Punctured Wound of the Heart, Terminating Fatally on the Fifth Day. Lancet, London, 1867, I, 115. Lindsley, V. S., Gunshot wound of the heart. Nashville Jour. Med. and Surg., 1867-68, n. s., Ill, 193-196. Wright, Brit. Med. Jour., London, 1869, II, 533. GUNSHOT, LACKRATKI), AND INCISED WOUNDS IO3 Buck, Pistol-shot wound of the Heart. Med. Rec, New York, 1869, IV, 209. Hart, Med. Rec, New York, 1870, V., 232. FiNNELL, Stab wound of the Heart and instantaneous death. Med. Rec, New York, 1870, V, 232. Fleming, Wound of the Heart. Dublin Quart. Jour. Med. Sc, 1870, XLIX, 499. Whipham, T,, The heart, left lung, and portions of the costal carti- lages of a man who shot himself. Tr. Path. Soc, London, 1870, XXI, 92. West, J. F., On wound of the Heart (thirty-four cases), St. Thomas Hospital Report, London, 1870, n. s., I, 237-275. Kemper, G. W. H., Remarkable exertion after a fatal gunshot wound through the heart. Indiana Jour. Med., Indianapolis, 1870-71, I, 237. Roberts, J. B,, Richmond and Louisville Med. Jour., Louisville, 1871, XII, 607-613. Dudley, G. F., Med. Arch., St. Louis, 1871, VI, 23. Ross, G., Case of wound of the left lung and heart. Canada Med. Jour., Montreal, 1871, VII, 256-275. Callender, W. G., Removal of a needle from the heart. Recov- ery of the patient. Proc. Roy. Med. and Surg. Soc, London, 1871-75, VII, 116; also Med. Chr. Tr., London, 1873, LVI, 203-212. Also Med. Times and Gaz., London, 1873, I, 212. Stevens, E. B., Remarks on injuries of the heart. Cincinnati Lancet and Obs., 1874, XVII, 523-526. Goss, F. W., Wound of the heart; probably from a knife. Boston Med. and Surg. Jour., 1874, XCI, 308. Knapp, M. L., Knife wound of the heart. Med. and Surg. Re- porter, Philadelphia, 1874, XXX, 379. H. R., Gunshot wound of the heart not immediately fatal. Indian Med. Gaz., Calcutta, 1874, IX, 65. Evans, G. H., Case of dilated heart from valvular disease. Right ventricle tapped by error, not only without harm, but with relief of the symptoms. Tr. Clin. Soc, London, 1875, VIII, 169-172. 104 THE SURGERY OF THE HEART Ford, C. L., Med. Rec, New York, 1875, X> i73- ViTE, J., Richmond and Louisville Med. Journal, Louisville, 1876, XXI, 151. Mellichamp, J. H., Charleston Med. Journal and Rev., 1876, n. s., IV., 17-20. Connor, P. S., Pistol wound of heart. Clinic, Cincinnati, 1876, X, 253-257. Also Trans. Lyon Med., 1877, XXVI, 50-54. Yemans, C. C, Wounds of the heart. Detroit Med. Jour., 1877, I, 481-484. Renaud, Gaz. Med. de Paris, 1877, p. 361. WiRTH, R., Wound of the heart. Ohio Med. Recorder, Columbus, 1877, I, 500-503. Gibney, V. P., New York Med. Jour., 1878, XXVIII, 634-636. Heil, Erichsen's Surgery, 1878, Vol. I, p. 626. West, of Birmingham. Erichsen's Sc. and Art. of Surg., Vol. II, 1878, p. 624. O'Neill, J., Remarkable injury of the heart. Indian Med. Gaz., Calcutta, 1878, XIII, 44. Ollivier and Sanson have collected twenty-nine cases of pene- trating wounds of the heart which did not prove fatal in the first forty-eight hours after injury. Erichsen's Sc. and Art of Surgery, Vol. I, 1878, p. 624. Jamain collected forty-eight cases in which people have lived for considerable time after having wound of the heart. Time seven hours to twenty days. Erichsen's Sc. and Art of Sur- gery, VII, 1878, p. 624. Bryant, Gunshot wounds of the heart are always fatal although not always immediately. (?) Practice of Surgery, 1878, p. 891. Hally, F. M., Med. Rec, New York, 1878, XIV, 476. Also Med. and Surg. Reporter, Philadelphia, 1879, XL, 188. Boone, W. H., Case of gunshot wound of the heart; death on the thirteenth day. Am. Jour. 0} the Med. Sc, Philadelphia, 1879, n. s., LXXVIII, 589. Boileau, J. P. H., Tr. Path. Soc. London, 1879, XXX, 278, also Brit. Med. Jour., London, 1879, I, 628. Plate XIII. An Oblique Penetrating Knife Wound of Left Ventricular Wall. A Longitudinal Penetrating Wound of the Heart, Showing How Wounds of the PIeart ]\L\Y BE Extra Pericardial. (Chapter on Wounds of the Heart.) GUNSHOT, LACERATED, AND INCISED WOUNDS 105 Dunham, Mr., A case of bayonet wound implicating both ventri- cles, the sa^ptum and the auricle. Patient lived forty-six hours and walked some yards after receiving the injury. Agnew, Surg., Vol. I, 424. Perforating shot wound of the left ventri- cle, which did not prove fatal for fifty-four days. London, Lancet, January, 1879. Rouse, W. H., Pistol-shot wound of the heart. Michigan Med, News, Detroit, 1880, III, 60. Robins, M. M., Med. Rec, New York, 1880, XVIII, 599. Duffel, J. E., A man lives three hours after being shot through both lungs and the left auricle of the heart. New Orleans Med. and Surg. Jour., 1880-81, n. s., VIII, 1145-1151. Sayre, L. a.. Bull. New York Path. Soc, 1881, 2 s., I, 6. Holmes, Syst. Surg., Vol. I, 1881, pp. 777-8. FiSHBOURNE, J. E., Gunshot wound case. Lancet, London, 1881 ; I, 851. Case, A. G., History and autopsy of a wound in the heart. Pitts- burg Med. Jour., 1882, II, 366-369. West, J. F., Suicidal pistol wound of the pericardium, heart and stomach; death in twenty-three hours. Lancet, London, 1882, n, 55. Jones, R. E., Gunshot wound. Tr. Miss. M. Ass., Jackson, 1882, XVI, 124. Coaxes, W., Wound of the heart. Indian Med. Gaz., Calcutta, 1882, XVII, 297. Simmons, Gross. Syst. Surg., 1882, Vol. II, p. 381. Randall, Dr., Tennessee. Syst. of Surg., Gross, 1882, Vol. II, 382. Carwin, F. M., Remarks on cardiac aspiration. Med. Rec, New York, 1883; XXIII, 263. Dana, Two cases of cardiac aspiration. Med. Rec, New York, 1883, XXIII, 140. Ward, S. B., Med. Ann., Albany, 1883, IV, 169-175. Kronecker and Schmey. Sitzungsberichted Berhner Akad, 1884, p. 87. AxFORD, W. L., Two cases of injury to the cardiac valves from sud- den violence. Med. Rec, New York, XXIII, 319. I06 THE SURGERY OF THE HEART Odenius, M. v., Skottsar genon hjartet ett bidrag till kammendo- men om det lefvande hjortets lage C. r., perforation du coeur par une balle de revolver; contribution a la connaissance de la situation du coeur vivant. Nort. Ark. Med., Stockholm, 1884, XVI, No. 20, II, 6-12. DoDD, A., Bayonet wound of heart; death from internal haemor- rhage; necropsy. Brit. Med. Jour., London, 1885, I, 379. Von Mosetig-Monhof, Ueber einen Fall von Schussverletzung des herzens. Wien. Med. Presse, 1885, XXVI, 179. Flynn, E. F., Wound of inferior vena cava and right auricle, death in seventy-five minutes. Brit. Med. Jour., London, 1885, I, 594- Von Hosslin, R., Nadel in herzen. Deut. Archiv }. klin. Med., 1884-85, XXVI, 588-595, 595-598. Duplaix, Archiv. de Med. Gen., 1885. Neal, J. C, Bullet wound of the heart. Med. Rec, New York, 1885, XXVII, 626. Chassaignac, C, Punctured wound of the heart. New Orleans Med. and Surg. Jour., 1885-56, n. s., XIII, 211. Miles, A. B., Gunshot wound of the heart. Ibid, 113-118. Lebeuf, L. G., Penetrating wound of the heart. New Orleans Med. and Surg. Jour., 1885-86, n. s., XIII, 543. Michel, J. E., An unusual case of gunshot wound. Atlanta Med. and Surg. Jour., 1886, XV, 40. Nicholson, G. F., Shot wound. Ball passed through both auri- cles and both lungs; patient lived forty-two hours. Med. New's, July 31, 1886, 123. HooPMAN, S. v., Gunshot wound of the heart. Med. Rec, New York, 1886, XXIX, 360. Kosteller, B., Two cases of wounds of the heart. Med. Obozr., Mosk., 1886, XXV, 733-735- Nicholson, G. F., Gunshot wound of the heart; patient survived forty-two hours after injury. India Med. Gaz., Calcutta, 1886, XXI, 143. ScHULTE, Drei falle von verletzung des herzens des bulbes aortae. Vrtljschr f. Gerichtl. Med., Berlin, 1886, XLIV, 308-311. GUNSHOT, LACERATED, AND INCISED WOUNDS 10/ Serra, L., Ferita d'arma da fuoco con lesions del cuorc senza ferita del pericardio, osservazione fatta in un caso d'amicide per doppio sparo d' arma de fuoci. Cagliara, 1886. Wyman, H. C, Wound of the heart. Med. Age, Detroit, 1886, IV, 505-509- MoRKRjiTSKi, Wound of the heart. Vratch, St. Petersburg, 1886, VII, 803. Thomas, D., Lancet, London, 1887, I, 230. LuKEN, M. A., Punctured wound of the heart. Med. pribav. k. Mosk. sborinku, St. Petersburg, 1887, 18-20. Karlinski, J., Contribution to knowledge of wounds of the heart by ricochet firing. Prazgl. lek, Krakow, 1887, XXVI, 155- 165. CuRRAN, W., Survivance after gunshot wounds or other injuries of the heart. Lancet, London, 1887, 673, 723, 850. Berout, Inaug. Dissert., 1887. CuRRAN AND Chevers, Cases illustrative of the vitahty of the heart under fire, as well as on pressure of cold steel. Med. Press and Circ, London, 1887, XLIV, 27-50. Machenaud, Plaie du coeur par une aiguille; hemopericarde du coeur, mort. Arch, de Med. Nav., Paris, 1887, XL VII, 375- 380. Francis, J. A., Survivance after gunshot wounds or other injuries of the heart. Lancet, London, 1887, II, 193. Baur, G. H., Ueber die schussverletzungen des herzens. Berhn, 1887. Raimondi, C, Ferita al cuore relazigne medico-legale. Rev. spr. dif Rygio-Emilo, 1887-88, XIII, Med. Leg. 8c^iii. Kravkoff, a. p., Russk. Med., St. Petersburg, 1887, V, 694- 696. Hahn, E., Demonstration einer nadel welche aus dem herzens eines medchens hurch extraction entfernt wunde. Verhandl. d. D. Gesellschft. Chit., Berlin, 1887, XVI, pt. I, 61. Stelzner, Mittheilung eineroperation behufs entfernung einer nehnadel aus dem rechten herzventrikel. Verhandle. d. D. Gesellschft. Chir., Berhn, 1887; XVI, pt. I, 58-61. I08 THE SURGERY OF THE HEART FuRBiN, Et spallitta Rimarchcvolc toUeranze di ferite al cuore. Gior. d. r. Acad, di Med. d. Soc, Torino, 1887, 3 s., XXXV, 367-374- Thompson, W., Brit. Med. Jour., London, 1888, I, 250. BoNANE, A., Ueber heilung der aseptischen herzwunden experi- mental forschungen. Centhl. j. d. Med. Wiss., 1888, XXVI, 625-627. BoNANE, A., Sulla guarigione delle ferite asttiche del cuore. Gior. d. r. Accad. Med. di Torino, 1888, 3 s., XXXVI, 403. Peabody, G. L., Med. News, 1888, LIII, 452; The literature of punctured and lacerated wounds of the heart. Med. Press and Circ, London, 1888, XLVI, 142-146. Martinotti, G., SuUi effetti delle ferite del cuore. Gior. d. r. Accad. di Med. di Torino, 1888, 3 s., XXVI, 405-414. Messerer, O., Darzereissung durch stoss mit der beschugten fusspitze Friederichs. Bl. }. Gericht. Med., Nuremb., 1888, XXXIX, 305-308. GoBiLLOT, Mort rapide par coup de pied de cheval, rupture du coeur sans lesions du thorax. Arch, de Med. et Pharm. Mil., Paris, 1888, XII, 281. Thomas, P. H. S., Twee hartverwondigen Nederl. Tijdschr. v. Seneesk., Amst., 1888, 2 r., XXIV, 2 d., 365-369. Charrin, S., Des blessures du coeur au point de vue medico- judiciaire. Lyon, 1888. Bellin, E. F., Medico-legal cases of wounds of the heart and large vessels. Russk. Med., St. Petersburg, 1888, VI, 429-442. Thomson, W., Tr. Royal Acad. Med. Ireland, 1888, VI, 345-349. Levy, A., Rupture traumatique du coeur sans plaie exterieure ni dechirure du pericarde. Arch, de Med. et Pharm. Mil., Paris, 1889, XIII, 201-203. Christiani, a ferita del ventriculo sinistro del cuore per arma purgente e teglientc, morte a giorni trenta nono dopo il feri- mento, sottura del cuore nel tossuto di cicatrice gia alia fase sclerotica. Spcrimcntalc, Firenze, 1889, LXII, 245-267. Morrison, W. F., Case of penetrating wound of the heart. Tr. Rhode Island Med. Soc, 1889, III, 561-565. GUNSHOT, LACERATED, AND INCISED WOUNDS IO9 Hare, H. A., The fatality of cardiac injuries. Med. and Surg. Reporter, 1889, LX, 729-731. BoNOME, A., Ueber die heilung der aseptischen herzwunden. Beit. z. Path. Anat. u. allg. Path., Jena, 1889, V, 265-274; i pi. White, G. A., Two cases of heart wound not instantly fatal. Oc- cidental Med. Times, 1889, III, 577-579. Krehl, Deutsche Med. Woch., 1889. Hall, R. M., Case of penetrating wound of the heart followed by septicaemia; death; post-mortem appearances. Med. Bull., Philadelphia, 1890, XII, 87. Magnan, Suicide par blessure du cceur avec une epingle mesurant k peine trois centimetres. Compt. Rend. Soc. Biol., Paris, 1890, 9 s., II, pt. 2, 35-41. Zenker, Verhandl d. X. Internat. Cong., 1890, II. Pond, H. M., Knife wound of the heart. Pacific Med. Jour., 1890, XXXIII, 430. Brenteno, G. a., Zur casuistik der herzverletzungen. Berlin, 1890. JosiONi, Un cas de plaie du cceur. Dauphine Med., Grenoble, 1890, XIV, 1 26-131. Schaefer, Verhandlung d. IX, Congress f. Innere Med., 1890. VoATS, J. A., A case of punctured wound of the right auricle of the heart; survived for nine days. Glasgow Med. Jour., 1891, XXXVI, 427-430. Joserand, G. N., Plaie p^netrante du coeur par instrument tran- chant, hemorrhagic inter-pericardiaque, mort vingt-quatre heures apres la blessure. Gaz. d. hop., Paris, 1892, LXV, 24, Kenyeres, B., Prolonged Hfe after penetrating wound of the heart. Gyogyasat, Budapast, 1891, XXI, 557. PoNCET, Plaie du cceur. Lyon Med., 1892, LXIX, 297. ZoEGE VON Manteuffel, Vorletzung der arterie und vena cor- onaria ventriculi dextra unterbindung heilung. St. Peters- burg Med. Woch., 1892, XI, 91. Peebles, G. H., Proc. Med. Soc. Nebraska. Omaha, 1892, iio- 112. His AND Romberg, Archiv. j. exp. Path. u. Pharm., 1892, XXX, 51. no THE SURGERY OF THE HEART Berent, a., Ueber die heilung von herzwunden mit besonder be- rucksichtigung der gravitzschen schlerminerzellen theorie nach versuchen am kannichen. Konigsburg, 1892. PoTAiN, Des traumatismus du coeur. Bull. Med., Paris, 1892, VI, 1525-1527. FoY, G., Some effects of wounds of the heart. Lancet^ London, 1893, I, 59. Delorme, Chir. de guerre, 1893. Marks, H., Two cases of stab wound of the heart. Med. Fort- nightly, St. Louis, 1893, III, 44-46. Elten, a., Ueber die wunden des herzens. Vrtljschrm. f. gerichtl Med., Berlin, 1893, V, 9-54. HocHHAUs, H., Ueber contusio cordis. Deut. Arch. Klin. Med., Leipsic, 1892-93, LI, 10-17. Heyl, a. B., Wound of the heart. Death at the end of three days. New York Med. Jour., 1893, LVII, 584. Berry, Bullet wound of the heart. Lancet, London, 1893, II, 1 188. Coats, J., Case of perforation of the heart. Tr. Glasgow Path, and Clin. Soc, 1891-93, IV, 37-43. LuMMiczER, J., Beitrage zur symptomatologie der verletzungen des herzens und herzbeutels. Ungar. Arch. }. Med., Wies- baden, 1893-94, II, 135-160. RiCHTER, M., Verletzungen aus zufall oder "nothwer" und ihre gerichtsortzUnke begutachtung. Prag. Med. Woche., 1893, XVIII, 473-475- MoERER, S., Une observation de plaie non penetrante du cceur par projectile de tres petit calibre (plomb No. 6). N. Montpel. Med., 1894, XXIX, 18. Field, F. A., Penetrating wound of the heart. Death in thirty- nine hours. Lancet, London, 1894, I, 474. Thompson, W., Report of a case of gunshot wound through the heart living thirteen hours. South Cal. Pract., 1894, IX, 48-51. Hall, R. M., Perforating wound of the heart. Boston Med. and Surg. Jour., 1894, CXXX, 431. GUNSHOT, LACERATED, AND INCISED WOUNDS I I I SoURRis, Lesion indirecte du coeur par un projectile dc guerre et de petit calibre. Jour, de Med., Bordeaux, 1894, XXIV, 281-283. Kerr, A case of gunshot wound of the heart. Med. News, 1894, LXV, 464. NoBiLiNG, A., Einiges uber herzwunden. Wien. Med. Presse, 1894, XXXV, 1 5 18-15 20. Hutchinson, F., Case of traumatic rupture of the heart. Brit. Med. Jour., Lonndo, 1894, II, 1427. Bell, Trans. Med. Chir. Soc, Edinburgh, 1894-95, p. 36. Laferqua, M., Des plaies du coeur de point de vue medico- legale, Paris, 1894. Kopo, C, Ueber die schussverletzung des herzens und der gefasse. Berlin, 1895. Mastin, C. H., Gunshot wound of the heart. Tr. Am. Surg. Ass'n, Philadelphia, 1895, XIII, 273-279. Del Vecchio, Rijorma Med., 1895, II, No. 79; also Centralhlatt }. Chir., 1895, p. 574. Deane, T., Knife wound of the heart. Pacific Med. Jour., 1895; XXXVIII, 209-211. Porter, Journal of Exper. Med., 1895, 1, 319. Finckh, Ein fall von schussverletzung des herzens. Med. Cor-bl. d. Wurtenb. Arztl., ver Stuttgart, 1895, LXV, 117. Rosenthal, Deutsche Med. Wochen., 1895, No. 2. Glazebrook, L, W., Stab wound of the heart. Med. News, 1895, LXVI, 508. HocHBERGER, J., Ein intcrcssante stichverletzung des herzens. Prag. Med. Woch., 1895, XX, 490. RoDET ET Nicolas, Sur les blessures du cceur. Gaz. d. Hop. de Toulouse, 1896, XL FerraresI, p., Recisione della mammaria interna di sinistra ferita del pericardio a del cuore. Gazz. Med. di Roma, 1896; XXII, 29-32. RiCHTER, M., Ueber den eintritt des todes nach stichverletzungen des herzens. Vrtljschr }. Gerichtl. Med., Berlin, 1896, XI, 16-46. 112 THE SURGERY OF THE HEART Ruth, Herzverletzung mit nicht sofort todlichen ausgange. Fried- erichs Bl. f. Gerichtl. Med., Nurmb., 1896, XL VII, 89-92. Pelkoff, V. N., Rare case of gunshot wound of the heart. Voy- enno Med. Jour., St. Petersburg, 1896, CLXXXV, i, sect. 305-310. Hanna, W. J., Transfixion of the left ventricle of the heart by a sharp wire with a second wound penetrating the wall of the ventricle. Occidental Med. Times, 1896, X, 440-442. PiSARZEWSKi, G., Gunshot wound of the heart terminating in death seven hours later. Medycyna Warszawa, 1896, XXIV, 721. Spencer, W. G., Punctured wounds of the right ventricle of the heart. Brit. Med. Jour., London, 1896, II, 1129. Salomoxi, Centralblat.j. Chir., 1896, No. 51. Turner, W., Remarks on wounds of the heart with notes on a case in which death took place four and one half minutes sub- sequently and cicatrization was shown post-mortem. Brit. Med. Jour., 1896, II, 1440. Englemann, Archiv }. d. Ges. Phys., 1896, XV, 119, 535. Sloan, Gould Year Book, 1896, p. iii. One of the Editors, Paracentesis with striking success in a case in which death was imminent from over distention. Gould Year Book, 1896, p. iii. Wounds of the heart, p. 671-754. Velpeau's Open Surg., Vol. I, by Mott. Crile on shock. Ex- perimental, 1897, p. 129. Puncture in Chloroform-Syncope. Watson's experiments from Paget's Surgery of Chest, 1897, 375- Williams, D. H., Patient died three years afterwards. Med. Rec, New York, 1897, LI, 437-439- Rehn, The successful treatment of a wound of the heart. Lancet, London, 1897, 1, 1306. Death in cases of wounds of the heart is due to pressure from effused blood in the pericardium. This pressure is a cause to check further haemorrhage. Op- erative procedure questionable. Gould Year Book, 1896, P- 337 VoiNiTCH, Sianojeusky Arch. Russ de Chir., St Petersburg, 1897; GUNSHOT, LACERATED, AND INCISED WOUNDS II3 II, also Reane dc Chir. Withdrawn and recovery in four weeks. Paget Surgery of the Chest. Ihid, 1897. Callender Needle Wounds of the Heart. Paget, Surgery of the chest, 1897, T~Z?>- Dr. Dana {New York Med. Rec, Feb., 1883). Paget, Surgery of the Chest, 1897, 376. Aspiration of air, emboHsm of heart through the jugular vein by catheter and aspiration. (Senus experiments, 1885.) From Paget on Surgery of Chest, 1897, p. 377- Callender, on needle wound of the heart. Paget, Surgery of the Chest, 1897, 135. Bode, Beitrage z. Klin. Chir., 1897, XIX, 167. In 1896 C. B. Nelson was shot. The X-Ray was used on him in April, 1896, and under the fiuoroscope the bullet could be seen plainly moving in the heart with each pulsation of the organ. Phila. Med. Journal, 1901, Vol. 7, No. 17, p. 797. Rehn, L., Ueber penetrirende herzwunden un herz naht. Berlin u. d. Verhandlg. d. Deutsch /. Chir. Leipsic, XXVI, 56-60. Schneider, G., Insuffisance aortique consecutive a un trauma- tisme du coeur. Med. Mod., Paris, 1897, VIII, 356. Blaisdell, F., Needle in the heart. Atlantic Med. Weekly, 1897, VII, 85. Bode, F., Versuche ueber herzverletzungen. Beit. z. Klin Chir., Tubingen, 1897, XIX, 167-21 1. SoNZALEZ Alverez, Aguja en el pericardio. An. r. Acad, de Med,, Madrid, 1897, XVII, 297-299. Parrozzani, Penetrating wound of pericardium and left ventricle; suture. Recovery. Lancet, London, 1897, II, 260. Booth, R. J., A case of punctured wound of the chest wall pene- trating the ileum and wounding the heart. Brit. Med. Jour., London, 1897, II, 469. Lennertz, L. J., Paris, 1897. Seemann, Zur kasuistik der herzverletzungen. Ztsch. j. Med. Bemte, Berlin, 1897, X, 643. Seross and Dodds, Autopsy in case of stab wound of the heart. Indiana Med. Jour., 1897-98, XVI, iii. 114 THE SURGERY OF THE HEART Prior, S., An unusual case of wound of heart. Recovery. Lan- cet, London, 1897, II, 913. Nebolyuboff, v., Homicide in self defence with perforating wound of the heart through the longitudinal sseptum. Vestnik Ohsh. hig. Sudeb i Prakt. Med., St. Petersburg, 1897, XXXIII, No. 63, Section 100-112. Feralli et Regnim, Le succession! marbrose di una ferita pene- trante del cuore. Gior. Med. d. r. esercito, Roma, 1897, n. s., XLV, 769-820; 2 pi. Ferrareri, p., Ferita per arma de punta della mammari intima di sinistra del pericardio a del cuore guarigione. Bull. d. Soc. Lancisiana d. osp. di Roma, 1897, XVIII, fasc. i, 312. ScHMEY, F., Ein traumatische rupture der mitralis. Allg. Med. Centhl. Ztg., Berlin, 1897, LXVI, 1070. Bird, U. V., Haemorrhage into the pericardium. Med. Rec., New York, 1897, LII, 701. Hutchinson, J., Foreign body lodged in the heart. Arch. Surg., London, 1897, VIII, 386. Morgan, G., Needle in the heart, urgent symptoms during ex- traction. Columh. Med. Jour., 1897, n. s., II, 592. Semeleder, F., Scheilte wunde des herzbeutels und das herzens. Tod durch bleutung. Wien. Med. Presse, 1897, XXXVIII, 1510. Garrat, a. H., Punctured wound of the heart. Canada Med. Review, Toronto, 1897, VI, 187. Spencer and Tippett, Tr. Clin. Record, London, 1896-97, XXX, 1-5- Seggel, R., Zur kasuistik des schussverletzung des scahdels an d. Stadt. Allg. krk. z. Mucnch. (1895), 1897, IX, 274-313. Mendelsohn, M., Ein fall von traumatischer myocarditis. Deut. Med. Woch., 1897, XXIV, Ver. beil, 25. Sbozgett, a. T., Gunshot wound of the heart. Brit. Med. Jour., London, 1898, I, 86. Leonpocher, Stich in das hcrz. Tod noch drei tagen. Fred- ericks Bl. /. Gerrichtl. Med., Nuremburg, 1897, XLVIII, 460. Fisher, J., Lancet, London, 1898, I, 434. Plate XIV. A Non-Penetrating Transverse Gunshot Wound of THE Left Ventricular Wall Dividing the An- terior Coronary Artery and Vein. (Chapter on Wounds of Heart.) GUNSHOT, LACERATED, AND INCISED WOUNDS II 5 Gluck, Fall von schussvcrlctsung dcs herzcns. Berlin. Klin. Woch., 1898, XXXV, 41. Hill, J. C, Punctured wound of thorax involving the pericardium and heart. Death six days after injury; necropsy. Med.Rec, New York, 1898, LIII, 411. OsTAN, E., L'intervention chirurgicale dans les traumatismes du coeur et du pericarde. Gaz. hebd. de Med., Paris, 1898, III. 193-198. Tossi, E., L'intercento chirurgico nelle ferite del cuore e del per- icardio. Bull. d. r. Acad. Med. di Roma, 1897-98, XXIII, 410-413. RuDis-JciNSKY, J., Stab wound of the heart. Recovery. New York Med. Jour., 1898, LXVII, 563-566. CuRA (la), Chirurgica nei traumatism del pericardio e del cuore. Clin. Chir., Milano, 1898, VI, 170-177. Neumann, A., Zur casuistik und behandlung die herzbeutel und herzverletzungen. Deut. Med. Woch., 1898, XXIV, Ver-beil, 90. PiCHT, Stichwunde des recten vorhofes. Tod nach sechs tagen. Ztsch. j. Med., Beamte, Berhn, 1898, XI, 491-493. Wound of the heart. Brit. Med. Jour., London, 1898, II, 828. Reichard, V. M., Wound of the heart. Med. Rec, New York, 1898, LXXIII, 535. Elsberg, C. a., Ueber herwunden und herzmaht. Centbl. f. Chir., Leipsic, 1898, XXV, 1070-1073. Behn, L., On the suturing of penetrating wound of the heart. Ann. Surg., 1898, XXVIII, 669-673. Beer, O. B., Thirty-seven years with a rifle-ball in the heart. Lancet Clinic, 1898, n. s., XLI, 496. Rydyger, Ueber herzwunden. Wien. Klin. Woch., 1898, XI, 1077-1079. Graziani, G., Influenza dello sforzo a del trauma sul cuore. Ri- jorma Med., Palermo, 1898, XIV, pt. 4, 518. The treatment of wounds of the heart (Edit.), Med. Rec, New York, 1899, LV, 93- AsKANDi, v., Contribuzione alio studio medico-legale di alume Il6 THE SURGERY OF THE HEART ferite del cuore suppl. al policlin. Roma, 1898-99, V, 161- 166. Ramoni, a., Duplice ferita penetrante nel ventricule destro del cuore; sutura guarigune. Gazz. Med. di Roma, 1899, XXV, 1-12. Meachem, J. G., Jour, of the Am. Med. Ass^n, 1899, XII, 178. LoisoN, E., Des blessures du pericarde et du coeur et de leur traitement. Rev. di Chir., Paris, 1899, XIX, 49-73. BuFFNOiR, Plaie du coeur par balle de revolver, essai de traitement chirurgical. Bull, et mem. Soc. Anat., Paris, 1899, LXXIV, 65. Lingo, N., Contributo all' intervente chirurgico nelle ferite del cuore e del pericardio, un cas di sutura del pericardio guari- gioni un caso di sutura dell cuore morte, Gazz. Internaz. di Med. Prat., Napoli, 1899, I, 12-26. Lingo, Chirurgie del cuore, un movo mezzo per obtenere I'emos- tari temporanea nelle ferite dei ventricoli. Gazz. d. osp., Milano, 1899, XX, 229-231. Reynolds, John, Surg. Hist. Am. War Surg., Vol. I. Velpeau, Stab wound left breast, diagnosed heart pierced; man died nine years later from other causes and cicatrix was found in pericardium and right auricle. Traite d'' Anatomic Chi- rurgicale, tom., I, p. 602. Terrier and Raynoud, Chir. du coeur et du pericarde, Elsburg, C. a.. Jour. Exper. Med., Vol. IV, Nos. 5-6, pp. 479- 520, 1899. Rose, Elsberg Jour. Exper. Med., Vol, IV, Nos. 5-6, 1899, p. 484. Romberg, Elsberg Jour. Exper. Med., Vol. IV, Nos. 5-6, 1899, p. 482. LoisoN, Revue de Chir., 1899, No. i, 2, 3 et seq. Weber, Elsberg Jour. Exper. Med., Vol. IV, Nos. 5-6, p. 503, 1899. HoFMANN, Elsberg Jour. Exper. Med., Vol. IV, Nos. 5-6, p. 503, 1899. Taugl, Elsberg Jour. Exper. Med., Vol. IV, Nos. 5-6, p. 503, 1899. GUNSHOT, LACERATED, AND INCISED WOUNDS IT/ Hill, L. L., Heart wounds, Med. Rec, New York, Dec. 15, 1900. Several cases of gunshot wound of the heart are reported in which the persons have walked various numbers of steps after the injury. Proc. Path. Soc. of Philadelphia. Beck, Numerous cases have been cited by Beck which have not been directly fatal. White and Stills, 2 ed., pp. 329-332, 580. Hennen, Military Surg., p. x, 464. Gunshot wound of the heart. System of Surg., Dennis, p. 499. Jackson, Mr., Rankin's Abstr., of the Med. Sciences, Vol., XXXI, p. 165. MuLLER, According to Tulpins (obs. Md. Lib. C-13), saw a case of wound of the right ventricle resulting in death nine days later. DiEMERBROCECK, Anat. Corp. Ham., LVI. Bartholin, Hist. Anat. et Med. rar. Vent, (hist 77). Injury left ventricle. Garmann, Eph. Nat. Car. obs. 114, p. 228. Incised wound of ventricle. Fantoni (L. c, p. 145) gives a case of a soldier who died seventeen days after a wound in the left ventricle. Fischer, Geo., Of Hanover. Langenbeck, Arch, fur Klin. Chir., B., IX, HH. S., 571, Berlin. Rose, Deutsche Zeitschr. }. Chir., XX, 329. Ollivier (1. c. p. 249) reports three cases of stab wounds of the left ventricle with empty and contracted heart. Heschl, Coup de Path. Anat., p. 176. Percy (Sanson Obs. nineteen) reports a case of sword or knife wounds of the heart, one hving nine hours after the right auri- cle had been laid open. Ange, Case of wound of the right ventricle. Died on the ninth day. Marrigues Remarques sur les plaies du coeur. Anc. Journal de Med., t. XL VIII, p. 244. Ray (Bonetus 1. c, t., Ill, p. 357) and Fantoni, Giorn. de di litter- ale d'ltal., t., XXI, p. 148, each had a case of wound of the right ventricle which died on the twTnty-third day. Koning, Lehrbuch de Chir., II. Il8 THE SURGERY OF THE HEART CoHNHEiM, AUgem. Patholog, I. GoLDEXBERG, ViTchoiv's Arcliiv, C, III, 88. Reedixger, Krankheiten des Thorax. Deutsche Chir., XLII, p. 1 80. MoRGAGXi, De sed. et Caus. Morborum, Epist. 69, Sect. 5. W.AiDEYER, Virchow's Arch., XXXIV, 473. RoHERT, Zingler's Beitrage X, 109. Bellys, Sepulcretum of Bonetus, t., Ill, p. 376, and Ollivier (1. c, p. 252) each report cases. BoYER, Foucrays Med. eclairee par les Sci. Phys., X. t. II, p. 92, reports wounds of Yentricles. Death five days later. DeWitt, Surger}', 1867. Smith, Stephex, Operation, Surger}-, 1887. Ollivier, M. M., axd Saxsex Der\^rgie, Med. Leg.,Vol. 2, 253, Variation is supposed to be due to the pecuhar arrangement of the muscular fibres of the heart. Right ventricle most frequent seat of injur}-. The Due de Berri, who was mur- dered in Paris in 1820, survived eight hours after having re- ceived a wound in the left ventricle. "Statistical obser^'a- tions on wounds of the heart, and on their relations to Forensic Med.," with a table of forty-two recorded cases by Dr. Purple; also Am. Jour. Med. Sciences, July, 1861, p. 293, for a case of bullet in the wall of the heart for twenty years. See, further, a paper, on Wounds of the heart, by Dr. Jno. Redman Coxe, Am. Jour. Med. Sci., Aug., 1829, p. 307; and Archiv. Gener. de Med., Sept. 1839, for a valuable paper On penetrating wounds of the heart, by M. Jobert De Lomballe, H. Holmes, Prof., of Montreal reports a case in which the right ven- tricle of a young man contained a linear opening, large enough to admit the finger without any wound in the pericardium, leading to the inference that the membrane had been driven before the ball and then forcibly distended. The ball was found loose in the chest cavity. System of Surger)', Gross, 1882, Vol. II, p. 381. Makixs, Surgical experience, South Africa, 1900. A CiviLiAX, War Hospital, 1901. GUNSHOT, LACERATED, AND INCISED WOUNDS IIQ Madia, E., Ann. di med. nav., Roma, 1901, II, 249. Gibson, Diseases of heart and aorta, 1901. Mauclaire, Independ. Med., Paris, 1901, VII, 73. Dacosta, Modern Surg. JocHMANN, Injuries of the heart vessels. Monatsschrift fur unjall heilkunde, Leipzig, Sept. 15, 1902, p. 277. FoucK AND Praum, Deutsche Medicinishe Wochenschrift, June 6, 1 90 1. Four cases gunshot wound not immediately fatal re- corded in Surg. Hosp. Am. War. Surg., Vol. I, p. 528, Hammond, L. J., Report of gunshot wound of heart. Annals of Surgery, Philadelphia, Pa., Oct., 1902, p. 550. Terrier and Reymond, Surgery of the heart and pericardium. Gazette Medicale de Paris, France, Nov. i, 1902, p. 636. Gibbon, J. H., Penetrating wound of the heart, Phila. Med. Jour., Nov. I, 1902, p. 636. ViGOT, Plaie de coeur. Annee med. de Caen, 1901, XXVI, 69-71. Madia E., Traumatism! del cuore dal punto di vista medico- legale. Ann. di med, nav., Roma, 1901, II, 249. Mauclaire, Des contusions du coeur et du pericarde. Ind. Med., Paris, 1901, VII, 73. Launay, p., Plaie double du coeur par balle (ventricule gauche) sutures guerison. Gaz. d. hop., Paris, 1902, LXXV, 925-926, Manine, J., Un cas de plaie penetrante du coeur survie de 34 heures, Gaz. hebdo. d. soc. med. de Bordeaux, 1902, XXIII, 423-427. Hammond, Levi J., report of a case of gunshot wound of the thorax involving the heart. Ann. 0} Surg., Philadelphia, 1902, XXXVI, 550-553- Wadsworth, W. S., specimen showing bullet wound of heart. Proceedings Philadelphia County Medical Society, Philadel- phia, 1902, IV, 13-14. Hammond, L. J., report of a case of gunshot wound of the thorax involving the heart. Proceedings Philadelphia Medical So- ciety, Philadelphia, 1902, IV, 206-209. Mauclaire, Les plaies du coeur et du pericarde. Independ. Med., Paris, 1 901, VII, 9. CHAPTER VI CARDIOCLASIA Etiology — Rupture of the heart may be due to injury or disease or both. Disease is conducive to traumatic rupt- ure, and rupture may occur without trauma at any time in disease. Fatty degeneration is the most frequent cause in advanced life, two-thirds being beyond sixty years of age, the proportion being about the same in each sex. It may be complete or incomplete and the opening of any size, single or multiple, which may or may not com- municate with each other. The fissures are usually parallel to the muscular fasciculi, unless abscess be present, when the opening may be of a perforating character. The edges are irregular and materially aid in the formation of clots, which have frequently been found in the opening. George II. and the Princess of Brunswick each succumbed to rupture of the heart. Historical (i 758-1 903). — Townsend (1832) found in twen- ty-five cases of rupture of the heart that three were of the right ventricle. Bayle found in nineteen cases that three were of the right ventricle. Reports of rupture of the va- rious chambers of the heart indicate that the left ventricular wall is most frequently involved, spontaneously or by trau- matic influence. Portal (1788) cites a death due to spontaneous rupture of the left ventricle. Matt (1815) states that the death of a young woman was due to rupture of the left ventricle; veri- fied by autopsy. 120 CARDIOCLASIA 121 This class of rupture was recognized by Watson (1828) in a case revealed by autopsy. Crass during the same year gives the notes of two cases shown by autopsy to be rupture of the left ventricle, as does Adams (1828) also. It would appear from Smith's (1836) case that fatty de- generation plays an important role as a factor in producing such a lesion. In his case of rupture of the left ventricle there was not only fatty degeneration of the heart, but free oil was abundant in the blood. Bodington (1843), Walshe (1844), Crisp (1846), Quain (1846), Fletcher (1847), Amry (1848), Coulson (1848), Ben- berg (1850), and O'Conner (1850), each report interesting cases of rupture of the left ventricle. The last-named gentle- man found rupture of the pericardium in addition to rupt- ure of the ventricular wall. This, no doubt, was due to trauma. Quain, White, and Hill each report a case of rupture of the left ventricle, the cause in each being attributed to aneu- rysm of the ventricle. Godden (1854), Fuinell (1857), Popham (1857), Coote (1861), Wilks (1864), Ramskill (1866), Meyer (1871), and Thomas (1883) each report a case of rupture of the left ven- tricle. The case of Meyer terminated in recovery. This is indeed a unique case and one from which many important deductions may be drawn. Blauvelt (1883) reports a case in which both ventricles were ruptured. In the case of Eraser (1897) the rent in the left ventricular wall was quite extensive. Thus it is shown that many varieties of rupture of the left ventricular wall may take place spontaneously and that fatty degeneration is probably the causative factor. Konskoff states that rupture of any of the heart fibres is rare, and that he found but three cases in 8,000 autopsies. Rupture of the right ventricle spontaneously or from trauma is very rare, as shown by the few recorded cases, 122 THE SURGERY OF THE HEART among the first of which are those of Ashburner, in which both ventricular walls were ruptured spontaneously. Chalice (1843), Learning (1844), Johnson (1851), Davis (1859), Duka {1862), Fennell (1869), and Prudden (1888) each report a case of spontaneous rupture of the right ventricular wall. In the case of Prudden the rupture was the result of general fatty degeneration from atheroma of the coronary arteries. Squire (1891) reports a case of rupture of the right ven- tricle with death at end of twenty-five hours, revealed by autopsy. Green (1894) reports a case of thrombosis and rupture of the right ventricle in a child nine and one-half months old. Hunter (1897) reports a death from an incom- plete rupture of the right ventricle with adherent pericar- dium. Thomas (1825), Rutherford (1828), Thomas (1830), Lankaster (1849), and Hall (1852), each report a case of spontaneous rupture of the rigJif auricular zvall. In the case of Hall there was an aneurysmal cavity in the substance of the ventricular sceptum of the heart. The rupture in the right auricle was sudden and fatal. Hudson (1859) mentions a case of rupture of the right auricle during labor. Cregen (1859), Finnell (1869), and Shearer (1872), each report a case of such a rupture. The case of Finnell is especially interesting in that autopsy re- vealed a small saccular aneurysm of the ascending aorta with hypertrophy and^fatty degeneration of the heart. Armory (1873) found by autopsy that compression of the thorax had ruptured the right auricular wall. Tennison (1879), Duffy (1881). and Thompson (1884), each record a case of rupture of the right auricle. Vase (1849), Clapton (1870), and Johnson (1877), each report a case of rupture of the left auricular zcall. There was an aneurysm of the ascend- ing aorta in the case of Johnson. Allen (1880) reports rupture of the left auricular ap- pendage of the heart. Mackintosh (1890) reports a case of spontaneous rupture of the left auricle. CARDIOCLASIA 1 23 Rupture of one or all of the cardiac walls from violence may occur at any age, and there are fewer cases reported than those of spontaneous rupture. Gariel (1835), Salkice (1839), and Geoghegan (1839), each report heart rupture due to violence. Fenner (1846) mentions a case of rupture of the heart with a compound fracture of the thigh in which the patient survived twenty-eight and a half hours. In the case of Carter (1847) it was the interventricular saeptum of the heart that was ruptured by violence. This was so in the case of Beith, except that in addition the rent extended through the walls of the right ventricle. In the case of Stanley the rupture involved both auricular walls. Leared (1852) mentions a similar case, while Hewitt re- cords a case of traumatic rupture of the ventricular saeptum of the heart without any laceration of the pericardium. Ward (1862), in reporting a case of heart rupture by external vio- lence, states that it was without break of the skin. Both Ellis and Oyler, during the year 1863, report cases of traumatic rupture in fatty degeneration of the heart with- out external manifestations. In the case of Oyler the lacera- tion occurred in the wall of the left auricle, which contained fibrous concretions undergoing softening in the same auricle. Mackenzie (1866) reports a case of rupture of the heart in a child, complicated with fracture of several ribs. This class of rupture is well established. The aorta may rupture independently, or it may be asso- ciated with rupture of any one or all of the cavities of the heart traumatically or idiopathically. Curling (1838) reported a case of rupture of the heart and aorta. Davy (1839) gave notice of a fatal case of rupture of the heart and aorta, with an account of some experiments on the power of re- sistance of the heart and great vessels. Hewitt (1846) gave cases of rupture of the heart and large vessels re- sulting from injury. Lewis (1883) reports a case of rupture of the aortic valves during severe muscular strain. Biggo 124 THE SURGERY OF THE HEART (1890) reports a similar case, due to a fall. Hektoen (1892) reports such an injury with aneurysm of the right auricular appendix. Rolleston (1890) reports a rupture of the aortic arch in connection with heart rupture, while Baylac reports rupture of the aortic arch. Williams (1896) records a case of rupture of the cardiac vessels. Eshner (1900) reports a case of rupture of an aortic leaflet in a case of right hemi- plegia W'ith aphasia due to cerebral haemorrhage. Rupture of the coronary arteries may he due to injury or disease and may involve any part of one or more vessels. Lally (1862) reports a case of rupture of the coronary artery wath obscure symptoms and death, and Cutler (1880) reports a case of embolism of the coronary artery with rupture of the heart. Josiasis and Betremeux (1884) report a case of atheroma of the coronary arteries. Steven (1884) reports a case of fatty degeneration and disease of the coronary arteries with cardiac rupture. Saivin (1887) reports a case of thrombosis of the coronary artery with rupt- ure of the heart. Armand (1889) reported spontaneous oblit- eration of the coronary artery in a case of Hodgkin's disease. Milan (1897) reports thrombosis of the coronary artery with cardiac rupture. Sherman (1871) cites a case of cardiac rupture due to violence. In the case of Shearer (1874) the patient died at the end of eight hours. Clayborn (1874), Whar- ton (1874), Hielt (1875), Packard (1877), Deheune (1878), and Finnell (1880) each report traumatic cardiac rupt- ure, the case of Finnell being due to indirect violence. Hanford (1880) reports a rupture from external violence without perforating wounds. Draper (1879) mentions a case of rupture of the interventricular saeptum of the heart in con- sequence of external violence. Bennett (1890) records a case of cardiac rupture complicated with fracture of the sternum and costal cartilages. O'Brien (1893) reports a similar case. Nibling (1896) writes on a case of heart rupture due to Plate XV. Section of Heart Muscle Showing Syphilitic Lesion. (Chapter on Syphilis.) CARDIOCLASIA 125 trauma, as does Bennett (1896) also, while Gibbons (1897) speaks of a case due to a blow by a stick, with survival for three hours. Oscar and Voelker during the same year report rupture of the ventricular saeptum. Ghedini (1897) also re- ports such a case. Newton (1899) mentions a case of a man twenty years old who was thrown upon a bicycle handle, fracturing and pushing the sixth costal cartilage into the apex of the right ventricle. Among other causes of heart rupture is tetanus, cases of this character having been reported by Ferguson (1883) and Duclaux (1878). There was one in a case of arsenical poisoning (?) reported by Lewis and Adams (1887) and one by Glikman (1893) during the act of defsecation, and one due to cold bathing. Several cases of heart rupture have been reported as hav- ing occurred in the insane during violent periods. Among them are those of Mickle (1883), Pichenot (1888 and 1889), also Nash (1892) and Beadles (1892). Rutchinski reports a spontaneous rupture of the heart. Hamilton (1903) records eight cases of heart rupture in in- sane subjects, six in the left ventricular wall, one in the right ventricular wall, and one in the right auricular wall. There were two openings in the right ventricular wall. BIBLIOGRAPHY Henroz, Observations sur une rupture du coeur. Jour, de med. Chir. Pharm., etc., Paris, 1758, IX, 516-518. MuMMSSEN, De corde rupt. Leipsic, 1764. 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Jour., Melbourne, II, 1880, 263. Draper, F. W., Boston Med. and Surg. Jour., CI, 1879, 3°^- DuEFEY, Dublin Quart. Jour, oj the Med. Sci., LXXII, 1881, 3 s., 84-87. CoRLEY, Rupture of the Heart. Dublin Quart. Jour. 0} the Med. Sci., 3 s., LXXII, 1881, 82-84. Barton, J. M., Rupture of Fatty Heart. Phila. Med. Times, XIII, 1881, 574. MACLEOD, Rupture of the Heart. Brit. Med. Jour., London, 1881, II, 1051. Klippel, Deux cas de rupture complete et spontanee du coeur. Bull, de la Soc. anat. de Paris, LVI, 181, 476-478. Bruen, Cancer of Liver and Rupture of Heart. Phila. Med. Times, XII, 1881-82, 649; Cases through cold bathing. Med. Press and Circ, London, 1882, n. s., XXXIII, 276. CouPLAND, Spontaneous Rupture of the Heart; Survival for Forty Hours; autopsy. Lancet, London, 1882, II, 939. MoLLiERE, H., Rupture spontanee du ventricule gauche causee par une thrombose de I'artere coronaire ; inondation pericardiaque ; mort foudroyante. Mem. et compt. rend, de la Soc. de med. de Lyon, XXI, (1881) 1882, pt. 2, 48-54. Franzuel, Rupture du coeur. Jour, de med. de Pouest, Nantes, XVI, I, 1882, 47. Rupture of the heart occurs frequently from external violence without any effect on the pericardium or any external skin marks. Syst. Surg. Grass. 1882, Vol. II, p. 381. 136 THE SURGERY OF THE HEART Beaumont, Recherches sur le5 lesions qui predisposent a la rupture spontanee du coeur, St. Denis, 1882. CouPLAXD, S., Spontaneous Rupture of the Heart; survival for Forty Hours; Autopsy; Remarks. Lancet, London, 1882, II, 939- Draxguel, Rupture du coeur. Bull, de la Soc. anat. de Nantes, 1881, Paris, V, 1882, 9. Baldwin, Specimen of Ruptured Heart. Lancet, London, 1883, II, 1093. Ferguson. F., Rupture of the Heart. Med. Rec, New York, XXIV, 1883, 584. Blal'\'ELT, H. C, New York Med. Times, XI, 1883-84, 14. JosL\s, Rupture spontanee du coeur, etc. Bull, de la Soc. anat. de Paris, III, 1883, LV, 237-241. Loving, Starling, 1883, reported to the Central Ohio Med. Soc'y a case of rupture of the heart in a Railroad Conductor as he attempted to pull himself upon the coach step. Levis, M. J., Phila. Med. Times, XIV, 1883-84, 583. Dunn, T. D., Rupture of the Heart. Med. and Surg. Reporter, Philadelphia, LI, 1884, 289. Green, A. W., Two Cases of Rupture of the Heart. Lancet, Lon- don, 1884, II, 317. Josias Betrexieux, Rupture spontanee du coeur; degenerescence graisseuse du coeur; atherome; caillot ancien de I'artere coro- naire anterieure; cirrhose cardiaque; nephrite interstitielle. Prog, med., Paris, XII, 1884, 48. Ross ANT) Merchent, Two Cases of Rupture of the Heart. Tr. of the Med. Soc. of the State of New York, 1884, 233-237. Baldwtn, Ruptured Heart. Brit. Med. Jour., 1884, I, 12. Pilgrim, C. W., A Case of Spontaneous Rupture of the Heart. Am. Jour. 0} Insanity, XLI, 1884-85, 305-308. Tompkins, H. H., Spontaneous Rupture of the Heart. Brit. Med. Jour., London, 1885, I, 891. Gron, K., Tilfaelde of skerose of arteria coronaris cordis. Med. Konsekuti myocardit pludselig. Dod. Norsk. Mag. }. Laegevi- densk, Christiania, XV, II, 1885, 1827. CARDIOCLASIA 1 37 Hadden, W. B., Two Cases of Rupture of the Heart. Brit. Med. Jour., London, 1883, II, 291; Rupture of the Heart; Acute Rheumatic Pericarditis and Fatty Degeneration. Rep. of the Sup. Surg. Gen., U. S. M. H. S., Washington, 1883, 234- MiCKLE, A. F., Cases of Spontaneous Rupture of the Heart in the Insane. Edlnh. Med. Jour., XXIX, 1883-84, 710-713. Wyckoff, C. C, Rupture of the Heart. Bufj. Med. Jour., XXIII, 1883-84, 297, 299. Mackenzie, J. A., Rupture of the Heart. Brit. Med. Jour., Lon- don, 1884, I, 3091. Dunn, T. D., Rupture of the Heart. Med. and Surgical Rep., LI, 1884, 289. Green, A, W., Two Cases of Rupture of the Heart. Lancet, London, 1884, II, 217. Merchent, R. L., Two Cases of Rupture of the Heart. Trans, of the Med. Soc. of the State of New York, 1884, 233-237. Champiel, Mort subite par rupture du coeur. Prog, med., Paris, XII, 1884, 1041. Leveque, E., Rupture spontanee et incomplete du coeur. Exam, histologique par M. Branet. Bull, de la Soc. anat. de Paris, LIX, 1884, 416-418. Peever, H. G., Case of Rupture of the Heart. Ind. Med. Jour., HI, 1884, 565- Steven, J. L., Cases of Spontaneous Rupture of the Heart and Remarks on Pathology of the Condition, with Special Refer- ence to Fatty Degeneration and Diseases of the Coronary Arteries. Glasgow Med. Jour., XXII, 1884, 413-427. FuSHER, T., Case of Rupture of Right Ventricle of the Heart. Tr. of the Path. Soc, London, XXXI, 1879-80, 72; i pi.; also Med. Times and Gaz., London, 1880, I, 23; also abstr., Brit. Med. Jour., London, 1880, I, 14. Thompson, G., Case of Rupture of Right Auricle of the Heart. Bristol Med. and Surg. Jour., II, 1884, 48-50. Purple reported two cases that did not prove immediately fatal. New York Med. Jour., May, 1885. 138 THE SURGERY OF THE HEART Hardy, H. N., A Case of Rupture of the Heart. Brit. Med. Jour., London, 1885, I, 891. Pelgrim, C. W., a Case of Spontaneous Rupture of the Heart. Am. Jour, oj Insanity, XLI, 1884-85, 305-8. Mattei, R., Di una doppia rottura del cuore per lipomatosi in- terstiziale del miocardio. Boll, delta Soc. tra i cult, delta Soc. med. in Siena, III, 1885, 186-189. Fereol, Retrecissement et thrombose de I'artere cardiaque gauche; rupture de cet organe. Gaz. des hop., Paris, XLIH, 1887, 134. Plastwich, De rupture cordis spontanea. Regimonti Pr. Panum, O. L., The Case of the late Prof. Panum, by Finer, trans- lated by H. Mygina. New York Med. Jour., XLH, 1885, 619. Robin, A., Sur les ruptures du coeur. Bull, et mem. de la Soc, med. des hop. de Paris, II, 1885, 401-406. Davega, T., Goutte chronique; rupture du cceur; mort rapide. Jour, de med. de Bordeaux, XV, 1885-86, 286. Mecondrew, H., a case of Rupture of the Heart. Brit. Med. Jour., London, 1886, I, 297. Trier, Ein Fall von Rupture des Herzens. Arch, fur klin. Med., VII, 1886, 657-661. Grant, O., Rupture of the Heart. Brit. Med. Jour., London, 1886 I, 928. Beck, H., Zur Kenntniss der Entstehung der Herzrupture und des chemischen partiellen Herzaneurysma. Tubingen, 1886. Von Limbeck, R., Zur Casuisytik der Herzruptur. Prag. med. Woch., 1886, XI, 403. McKeough, Rupture of the Heart. Canada Med. and Surg. Jour., Montreal, XV, 1886-87, 369. Foot, A. W., Spontaneous Rupture of the Heart. Tr. of the Acad. of Med. in Ireland, IV, 1886, 335. Lewis and Adams, Weekly Med. Review, St. Louis, XV, 1887, 144. Saivin, Bost. Med. and Surg. Jour., CXVII, 1887, 37. Friberger, R., Fall of hjcrruptur mod bristning of pericardium ups ala lakaref. Forh., 1886-67, XXII, 439-442. Holmes, J. C, Rupture of the Heart. Med. and Surg. Reporter, LVII, 1887, 479. i CARDIOCLASIA 139 Neelson, F., Uebcr spontanc Ruptur des Hcrzcns durch Vcr- schluss der Coronarterie und hammorrhagischcn Infarctc dcs Herzmuskels ncbst Bemerkungen iibcr die Genese Ham- morrhagischer Infarcte. Beit. z. path. anat. u. Klin., Leipsic, 1887, 113-133- Meilhon Megelomane, Mort subite par rupture du coeur. Ann. med. psych. Paris, VI, 1888, 236-244. Reddy, H. L., Rupture of the Heart. Canada Med. Record, Mon- treal, XVI, 1887-88, 100. Galassi, G., Contributo alia casuistica della cardioresi spontanee. Boll, della Soc. lancisiana degli osp. di Roma, VII, 1887, 54-57- Hun, H., Traumatic Rupture of the Valves of the Heart, Albany Med. Ann., IX, 1888, 161-163. MuER, J. S., A Case of Spontaneous Rupture of the Heart; Ne- cropsy. Glasgow Med. Jour., XXIX, 1888, 378-384. Prudden, T. M., Proc. of the New York Path. Soc, 1888, 195. Meyer, G., Zur Kenntniss der spontanen Herzruptur. Deutsch. Arch. }ur klin. Med., XLIII, 1888, 379-408. Roche, Ruptures spontan^es du cceur. Bull, de la Soc. med. de Lyon, 1887, Auxerre, XXVIII, 1888, 97-105. Agnew, Surgery, Vol. I, 1889, 422-423. Gamgee has reported twenty-eight cases of rupture of the heart by external force. Right and left side equally affected. Ag- new's Surgery, Vol. I, 1889, 423. Tezjokoff, N. I., Case of Spontaneous Rupture of the Heart. Med. Obozr., Mosk., XXXII, 1889, 104. GuLLEMANT, JuLES, J. B. L. M., Consideration sur quelques ob- servations de rupture spontanee du cceur. Bordeaux, 1889 Crocker, J. H., Case of Rupture of the Left Ventricle of the Heart. Lancet, London, 1890, I, 17. Biggs, H. M., New York Med. Jour., LI, 1890, 76. Armaud, F., Marseille med., XXVI, 1889, 703-710. Mackintosh, M., Lancet, London, 1890, 1, 239. White, W. H., Unusual Form of Rupture of the Heart. Tr. of the Path. Soc. of London, XL, 1888-89, 58. I40 THE SURGERY OF THE HEART Mallet, H., Rupture spontanee du coeur. Bull, de la Soc. anat. de Paris, LXIV, 1889, 400-405. PiLLiET, Rupture du coeur. Ihld, 478. Mackenzie, S. C, Simple and Complicated Rupture of the Heart. Indian Med. Gaz., Calcutta, XXV, 1890, 105. PiNCHENOT, Bull, de la Soc. de Med. de Lyon, 1889, Auxerre, 1890, XXX, 69-75. Hebb, R. G., Rupture of the Heart. Tr. of the Path. Soc. of Lon- don, XLI, 1889-90, 41. Bennett, E. H., Tr. of the Royal Acad, of Med. in Ireland, VHI, 1890, 392-394. Squire, C. L., Med. Rec, New York, XXXIX, 1891, 621. Tretzel, L., Ruptur einer Aortenklapper in Folge korphcher An- strengung. Berl. klin Woch., XXVIII, 1891, 1073. Karplus, R., Ein Fall von penetrirender Herzwunde mit Embolic des Gehirns. Wien klin Woch., IV, 1891, 699-702. Richards, J. P., A Case of Fatal Injury to the Pericardium and Heart; Necropsy. Lancet, London, 1891, 1, 11 51. Bruce, J., Case of Rupture of the Left Ventricle of the Heart. Jour. 0} Ment. Science, London, XXXVIII, 1892, 85. Nash, V., Jour, of Ment. Science, London, XXXVIII, 1892. Rouse, E. R., Case of Ruptured Heart. Lancet, London, 1892, I, 310. Hektoen, L., N. Am. Pract., IV, 1892, 157-163. MuDD, B. W., Ruptured Heart. Lancet, London, 1892, I, 578. RoLLESTON, H. D., Tr. of the Path. Soc. of London, XLII, 1890- 91. 57- Hern, Max., Ueber einen Fall von Spontane Herzruptur. Kon- igsburg, 1892. Merklen, p., Mort subite par rupture du coeur sans epanchement de sang dans le pericarde. Bull, et mem. de la Soc. des hop. de Paris, LX, 1892, 813-818. Glasson, O. J., Death from Rupture of the Right Ventricle of the Heart. Med. Times and Hospital Gaz., London, XXI, 1893, 173- Glikman, Z., Russk. Med., St. Petersburg, XVIII, 1893, 10. 3 CARDIOCLASIA I4I O'Brien, C. M., Med. Press and Circ, London, LVI, 1893, 353. Coats, J., Rupture of the Heart. Tr. of the Glasgow Path, and Chn. Soc, IV, 1891-93, 43. Deane, C. M., a Case of Rupture of the Heart. Australas. Med. Jour., XV, 1893, 471. Kakorski, K., Spontaneous Rupture of the Heart. Bolnitsch Gaz. Botkina, St. Petersburg, IV, 1893, 1143-1150. Beadles, C. F., Tr. of the Path. Soc. of London, XLIV, 1892, 18- 23- Webersberger, Ein Fall von Herzruptur. Deutschmil., arzil. Ztschr., Berlin, XXIII, 1894, 305-310. Gaevert, C, Un cas de rupture spontanee du coeur. Flandre med. II, 1895, 641-645. Guillemont, L., Rupture du coeur. Ibid., 599-561. Jay, Rupture du coeur. Bull, de la Soc. anat. de Paris, LXX, 1895, 497- Ramond, F., Dislocation segmentaire du myocarde dans un cas de coeur force. Bull, et mem. de la Soc. med. des hop. de Paris, XII, 1895, 796-799- Robin et Nicolle, De la rupture du coeur. Paris, 1895. Baylac, J., Arch. med. de Toulouse, 1895, 94-118. CoLLiNGS, D. W., A Case of Thrombosis and Rupture of the Heart in an Infant. Brit. Med. Jour., London, 1895, 1, 1202. Penneato, p., Rottura del cuore. Rev. veneta di sci. med. Vene- zia, XXI, 1894, 506, 508. QuAiN, R., Fatty Degeneration of the Heart Causing Death by Rupture of the Left Ventricle. Tr. of the Path. Soc. of Lon- don, III, 269-271. Sanduine reports a case opening in the base of an ulcer in the heart (left ventricle). Quart of blood in the pericardium. Presse med.. No. 15, 91. Green, Am. Jour. 0} the Med. Sci., Dec, 1894. Embley, Rupture in an Aneurysmal Dilatation of the Left Ven- tricle. Australian Med. Jour., x\ugust 20, 1895. COLLINGS reports a case of spontaneous rupture of the heart in a man aged fifty-three years. Lancet, April 20, 1895. 142 THE SURGERY OF THE HEART Kauskoff, Presse med., March, 1896. Peron, a., Rupture spontanee du coeur. Bull, de la Soc. anat. de Paris, LXX, 1895, 197. Rankin, G., Rupture of the Heart. Birmingham Med. Rev., XXXVIII, 1895, I ic^i 15. Shiperovich, M. v., On Spontaneous Rupture of the He;, it. Bol- nitsch Gaz. Botklna, St. Petersburg, VI, 1895, 681-71 1. Stoent:scu, N., Morte subite un irma rupturei spontanee a cardului stang. Spitalul, Bucurasci, XV, 1895, 64-67. Tarxier, J. A., A Case of Spontaneous Perforation of the Heart with Obscure Sjnnptoms. Boston Med. and Surg. Jour., CXXXIII, 1895, 62-66. Williams, H. U., Rupture of the Left Ventricle. A Study of a Case. Med. Rec, New York, XL VII, 1895, 618. NiBLiNG, A., Friederichs Bl. /. Gerichtl. Med., Nuremberg, 1896, XLVII, 93-102. Samgin, v., Rupture of the Heart due to Rheumatic Ulcer- ative Endocarditis. Med. Obozr., Mosk., XLV, 1896, Bartikovski, Ein Fall von auscheinender Neuritis und tod durch Herzruptur. Aertzl. sachverst. Ztg. Kelynack, T. N., On Spontaneous Rupture of the Heart. Lan- cet, London, 1896, II, 165. Pcholin, On Spontaneous Rupture of the Heart Muscle. Voy- enne-Med. Jour., St. Petersburg, CLXXXVI, 1896, i Sect. 200-207. Nebolyuboff, V. P., Rupture of the Heart due to a Fall from a Height. Dnevnik. Obsh. Vrach. Pri. Imp. Kazan. Univ. (1895) 1896, 41-44- Simpson, F. S., Case of Rupture of the Heart. Brit. Med. Jour., London, II, 1896, 654. Cole, G., Fatty Degeneration and Rupture of the Heart. New Albany Medical Herald, XVI, 1896, 295-297. Williams, J. W., Lancet, London, 1896, II, 1678. Robertson, C, Note on a case of Rupture. Lancet, London, 1897, I, 240. Pl-AIE XVU. X 200. Fibroid. X so. Lipoma. (Chapter on Benign Tumors.) CARDIOCLASIA I43 Bennet, E. H., Trans, of the Roy. Acad, of Medicine in Ireland, XIV, 1896, 303-306. Cantieri, a., Delia roltura delle valvule cardiachc in seguito a sferzo violente od a trauma. Clin, med., Pisa, III, 1897, 19, 34, 47- Fraser, J. A., Brit. Med. Jour., London, 1897, I, 783. Groom, W., A Case of Rupture of the Heart. Lancet, London, 1897, I, 1202. Kaufmann, E., Herz einer 68 jahrigen arbeitarwitere mit innerer Rupture. Allg. Med. Ztg., Berlin, LXVI, 1897, 517. MiLiAN, G., Bull, de la Soc. anat. de Paris, LXXII, 1897, 436- 438. Brady, E. T., Case of Rupture of the Heart. Virginia Med. Semi- monthly, Richmond, II, 1897-98, 233. Shelby, C. P., Jr., Rupture of the Heart. Med. Rec., New York, LII, 1897, 319. Brayton, a. W., a Case of Rupture of the Heart. Ind. Med. Jour., XVI, 1897-98, 208. Hunter, D., Lancet, London, 1897, II, 1583. Gibbons, J. B., Indian Med. Gaz., Calcutta, XXXII, 1897, 443- 445- Farnarier, F-, Un cas de rupture du coeur droit. Marseille med., XXXV, 1898, 136-140. Fox, R. H., Rupture of the Heart, Non-perforating. Tr. of the Path. Soc. of London, XLVIII, 1896-97, 49-51. DuPLAUT, Berlin klin. Woch., Dec. 5, 1898, Reports a case of rupt- ure with death six days later, due to breaking down of an ol'd infarct. Greig, W. J., Spontaneous Rupture of a Fatty Heart. Can. Pract., Toronto, XXIII, 1898, 80. Oscar and Voelker, Tr. of the Path. Soc. of London, XLVIII, 1896-97, 47. Pelon, H., Des ruptures dites spontanees du coeur. Prog, med., Paris, VII, 1898, 385-387- Amyot, J., Ruptured Heart. Canad. Pract., Toronto, XXIII, 1898, 441. 144 THE SURGERY OF THE HEART Meshiret, Un cas de rupture spontande du coeur. Jour, de med. de Bordeaux, XXVIII, 1898, 103. Ghedini, a., Atti. delta Acad. d. Sci. med. e nat. in Firenze, LXXII, 1897-98, 133-168; I pi. Hampeln, p., Ueber Herz und Aortenruptur. St. Petersburg Med. Woch., XV, 1898, 419-422. Nebolyuboff, Idiopathic Rupture of the Heart. Dnervmk, Obsh. Vrach. Pri. Imp. Kazan Univ., 1898, 140-42. Newton, Medical Record, June 17, 1899. Sutcliffe, J., A Case of Rupture of the Heart. Brit. Med. Jour., London, 1900, I, 142. Kalenberg, a., a Case of Rupture of the Heart. Indian Med. Rec, Calcutta, XVIII, 1900, 78. HuYGHE, Deux cas de rupture du coeur. Nord. med., Lille, VII, 1900, 74-77. Goodman, P. T., Case of Spontaneous Rupture of the Heart and haemorrhage into the Pons Varolii. Lancet, London, 1900, I, 1067. EsHNER, A. A., Med. Dial., II, 1900, 201. Prochazka, Fr., Casop. lek. cesk. Praha, XI, 1901, 532-535; 587- 591- Bergmann, Ein Fall von subcutaner traumatischer Ruptur des Herzens und Herzbeutels. Monatschr. }. Unjallheilk., Leipzig, VIII, 1901, 15-17. FiEROFF, J. M., Sur les ruptures traumatiques du coeur. Med. Obozr. Mask., LV, 1901, 352-357. Durst, F., Ruptura traumatica cordis (atrii sin.); haemoper- cardium. Liecnicki Viestnik Zagreb, XXIV, 1902, 223- 224. Thomson, E. M., A Case of Rupture of the Heart. Brit. Med. Quart., London, I, 1902, 453. Bergmann, Ein Fall von subcutaner traumatischer ruptur des Herzens, und Herzbeutels. Monatschr. }. Unjallheilk., Leip- zig, 1901, VIII. Fleroff, J. M., Sur les ruptures traumatiques du coeur. Med. Obozr., Moskow, 1901, LV, 352-357. CARDIOCLASIA 145 Procharzka, Fr., Dcs ruptures spontan^es du coeur. Cassop. lek. cesk. Praha, 1901, XL, 532-535; 587-591- Durst, F., Ruptura traumatica cordis (atriisin) haemopericar- dium. Liecnicki Viestnik Zagreb, 1902, XXIV, 223-224. Thomson, Eric M., A case of rupture of the heart. Brit. Med. Jour., London, 1902, I, 453. Slajmer, E., Contribution a la casuistique de la blessure du coeur avec consideration speciale des corps etrangers. Liecnicki Vestnik Zagreb, 1902, XXIV, 305-309, 2 fig. CHAPTER VII CARDIORRHAPHY—CARDIOTOMY— HEART SUTURES There is probably no organ or disease about which so much has been said and written, with so Httle accompHshed, as the heart with its diseases. Historical (1871-1903). — Until 1871, when Callender re- moved a needle from the heart, there is no recorded case of human heart injury in which anything surgical was attempted. He was succeeded by Goodheart, who cured a case of hydatids of the heart by a surgical operation in 1876. The heart may be injured even to the point of laceration without injury to the pericardium, and vice versa. Both, however, are found wounded in either event, whether by direct or oblique contact. A penetrating wound of the heart may occur in its base from above, without injury to the peri- cardium. The right ventricle is more frequently injured than the left, and the mortality greater in the left. The auricles ^re protected by the sternum. Loison says that death varies with the position, size, and character of wound, and in general 85 per cent, of all heart wounds are fatal. It is said that a large proportion of deaths are due to effusion of blood into the pericardial sac, causing over- distention. This is hardly probable when the pericardium is incised or lacerated. Reports of death from heart injury are very untrustworthy unless verified by autopsy. Billroth condemned any attempt to suture wounds of the heart, Riedinger (1884), Tillmanns, Rosenthal, Del IKt CARDIORRHAPHY-^ARDIOTOMY — HEART SUTURES I47 Vecchio, Solomoni, and Bode each discouraged any attempt whatever at suturing wounds of the heart. Stevenson (1887), concerning heart wounds in war, says that no method of treatment is hkely to be of permanent service towards their cure. Druitt (" Surgery," 1867, page 456) says that " opium is the only available remedy " in injuries of the heart, wdiile Stephen Smith, as late as 1887 (page 257 " The Principles and Practice of Operative Surgery "), says the first aim is clot and to induce it, and that fluid should be drawn oiT with a tro- car. He does not mention suturing or anything surgical, but says (page 277, " Operative Surgery ") that " the only operation on the heart and pericardium is undertaken for dropsy." Ashhurst (International Encyclopedia, Vol. VII, page 813) says that there is nothing to be done in wounds of the heart. This statement was made as late as 1889. AVharton and Curtis ("Surgery," 1898, page 878) say, con- cerning foreign bodies in the heart, that their removal should be attempted if their position can be located and their pres- ence causes marked disturbances. Da Costa says that suture in case of laceration of the heart should be attempted and that fine silk should be used. Paget (" Surgery of the Chest," page 373, 1897) says small wounds do not need suture and large ones give no chance for it. Makins (1901, "Surgical Experience in South Africa," pages 383, 384) says that perforating w^ounds of the heart were probably fatal in all instances, but that several cases occurred in which the surface of the heart was scored by bullets, and that in the case of Cheatle death resulted from suppurative peri- carditis; both the auricular and ventricular walls had been scored. Makins believes that death was often due to sud- den stoppage of the heart and not haemorrhage from it. He reports six interesting cases of gunshot wounds of tissues in close proximity with the heart, as shown by autopsy, 148 THE SURGERY OF THE HEART demonstrating their influence upon the action of both the heart and lungs. The history is of more or less importance, and while there is but little time, if any at all, to secure a history in cases of emergency, it should be accurately detailed ill cases of election. To know the position of the body, whether erect or recumbent, at the time of injury, will often enable the character of the injur}- to be more accurately determined, as the heart changes its position materially with these postures. Weapon, Knife or Gun. — In the case of wound with a knife, the characters of the blade, whether sharp or blunt-edged, pointed or rounded at the end, narrow, thin, wide or thick, are all of the greatest importance. The size of the gun, the character of the ball, one or more in number, whether of lead or steel, soft or hard, jacketed or not, the distance it travelled, and the angle at which it entered the body, are of importance. Age, sex, and general physical condition at the time of injury are to be noted, also whether other injuries have been inflicted upon the body at the same time. Note, too, ex- posure (if any) of the body to the sun, heat, cold, rain, or wind, and the time of injury following the eating of a meal. Comphcations such as new growths, disease, deformity in general, or of the chest in particular, are quite common. Symptoms. — External signs of injury may or may not be present. If present, there may be puncture, laceration, con- tusion, or slight or extensive ecchymoses. Crepitus may be present; if so, it may be due to a fract- ured rib or cartilage or to emphysema. These may exist without external manifestations. A foreign body may induce crepitus. Haemorrhage may be of an oozing character, it may pulsate or flow steadily, mildly or excessively, and its char- acter, whether venous or arterial, cannot, as a rule, be de- termined. If pulsating, it may be due to the escape of blood from the heart or the internal mammary or intercostal artery CARDIORRHAniY— CARDIOTOMY— IIEARI' SUTURES I49 or one or more of the pulmonary vessels. One or all of these may be injured at the same time, with or without pulsating hemorrhage. The haemorrhage may be exposed or concealed (external or internal), single or combined, with or without dulness in either event. If there is dulness upon percussion, the area increases with increased ha^nnorrhage, which may escape into a cavity of the chest or that of the abdomen. The heart's action becomes more rapid, irregular, and feeble, threadlike or tumultuous. Its sounds are less distinct, be- coming more indistinct as haemorrhage increases, whether it be concealed or exposed. There is sometimes to be heard a metallic tinkling or whizzing sound, resulting from the air in the pericardium. Nietert says: " I have observed and operated upon four cases of penetrating wounds of the pericardium in which there was bleeding into the pericardial sac. In these four cases there was a communication of the sac with the pleural cavity, and in each instance the splashing sound was audible. I conclude, therefore, that the absence of the sound is due to increased intrapericardial pressure, produced by an accumu- lation of blood. This accumulation is due to the absence of an avenue of escape, there being no communication with the pleural cavity. Therefore, the splashing sound audible over the region of the heart, in injuries of this kind, seems to be an important sign in connection with the diagnosis, as it determines whether the pericardial sac communicates with the pleural cavity or not." Cyanosis is usually present, varying in degree, depend- ing upon the size of the wound and amount of haemorrhage and interference with respiration. Dextrocardia. — The heart may not be in its normal posi- tion, and for that reason escape injury when it occurs in the heart's normal position, or the position commonly known to be that of the heart. Sometimes the heart is pushed forward as a result of fluid behind it. Orthodiagraphy may be used 150 THE SURGERY OF THE HEART to determine the position of the heart or the presence of a foreign body. Moritz mentions sixteen cases in which he could determine the oiitHnes of the heart with the x ray {Munchcncr Med. Woch., January 7, 1902.) The temperature is usually subnormal. It may be normal or it may be higher, depending upon the amount of shock from the injury itself, or excitement incident to it, or both, exposure to heat, cold, water, air. the sun, or rough handling. Perspi- ration may be mild or profuse, or it may be absent entirely. Pallor may vary in degree, or it may be absent, but is usually present. Respiration may be difficult and vary in degree. The difficulty is supposed to be due to pressure upon the lungs by the escape of blood into the pericardial or pleural cavities, but it may be present without these conditions. Sighing, yawning, and gasping may manifest themselves separately or combined at any time between the injury and recovery or dissolution. Facial expression is markedly changed, indicating great distress and anxiety, and this sign is usually present. Mental excitement varies from a mild degree to that of delirium and unconsciousness. Delirium coming on after a few days indicates pysemic cardiac abscess. The general nervous system suffers greatly as a rule. There is more or less muscular contraction, with a slight hack- ing cough and restlessness to the point of general convul- sion. The patient will sometimes claw at his clothing or, if lying upon the ground, will pull at the grass, dirt, or weeds, or anything he can grasp. Treatment. (1) Sanitary — Stimulants should be given with great caution, especially before the opening in the heart is closed with suture. The amount of bleeding from an opening in the heart is greatly influenced by the strength and number of beats. A recumbent position and perfect quietude should be maintained with the patient and his surroundings. Hot or cold draughts of air. rain, snow, and the sun's Plate XVIII. X 110. AnGEIO'MA. >• ' "^Sfe^T'^' . .'j/ X 2.jU. Myxomatous Tissue. (Chapter on Benign Tumors.) CARDIORRHAPHY — CARDIOTOMY — HEART SUTURES 151 rays should be excluded. Artificial heat should be applied, and tight, unclean, or superfluous garments removed. Ex- clude all but necessary attendants and relieve pain with hypo- dermic injections of morphine. Transportation of the patient should not be attempted. If necessary, it should be done on a stretcher carried by men. (2) Surgical — Aseptic principles should be applied in every step of the operation and throughout the care of the wound. No time should be lost in deciding upon what is to be done in each individual case. If the patient is uncon- scious, anaesthesia will not be necessary. In many cases in which the patients are conscious anaesthesia cannot be induced because the loss of time necessary to produce anaesthesia would be fatal. There can be no fixed rule as to whether or not anaesthesia should be produced, each case having its individ- uality. Morphine given subcutaneously at time of injury will probably prove efficacious in lessening pain and shock in patients who cannot bear anaesthetics. If possible, reach the opening in the heart without open- ing the pleural cavity, but if the pleural cavity has been opened by the primary injury, the opening should be enlarged to admit of ample room to expedite suturing. Giardano advises following the canal of the wound to the pericardium and heart rather than making an osteo- plastic flap, as it might be sufficient to stop haemorrhage through a small opening in this way. If this course is not followed, a semicircular incision is made to divide the soft tissues overlying the sternum. The cartilages of the fifth and sixth ribs on the left side are severed near the sternum, then by means of the rongeur a sufficient portion of the sternum is removed to bring the cut in the pericardium plainly into view. If necessary, the opening in the sternum may be en- larged. The wound in the pericardium may also be enlarged to facilitate the work. Gelatin given subcutaneously, by the stomach, or by the rectum, is said to be beneficial in arrest- 152 THE SURGERY OF THE HEART ing haemorrhage from wounds of the heart as in other locali- ties. Historical Surgery of the Pericardium. — Baron Larrev (1798) was the first deliberately to plan the removal of, and to remove, fluid from the pericardial space. This he did by introducing a hollow needle between the seventh rib and the ensiform cartilage. (Memoires de Chirurgie, Milan, t. Ill, page 458.) The best anatomical route would appear to be between the sixth and seventh ribs, one inch to the left of the sternal margin. The internal mammary artery is a little external to the side of the sternum, and the intercostal artery at the lower margin of the rib. Romero incised the pericardium in 1801 with a needle, and aspirated it in three cases in 1819, in two of which the patients recovered. Jowett (1827), Wheelhouse (1866), and Tiele (1869), each punctured the pericardium. Goodhart (1876) cured a case of hydatids of the pericardial sac by as- piration. West (1883) collected eighty cases of aspiration of the pericardium for various causes. Leyden (1881) was the first to make an incision in the pericardium to evacuate fluid. In his case the fluid was pus and the patient recovered. Riolan was the first to trephine the sternum for the pur- pose of opening the pericardial sac. John C. Warren (1852) was the first American to remove fluid from the pericardia] sac with a needle successfully. Trousseau did not give Larrey the credit of being the first to open the pericardial sac with a needle. Trousseau not only adopted the method of Larrey and Desault, but the point of puncture also. The heart is pushed forward in the great majority of cases by fluid within the pericardium. This of itself should preclude the advisability of plunging a trocar into the peri- cardial sac, for the reason that the needle must of necessity pass through the heart to reach the fluid behind it. ("Surgery of the Pericardium.") CARDIORRIIAPIIY — CARDIOTOMY — HEART SUTURES I 53 Wyman reports a case in which the bursting of a circular saw tore away a portion of the fifth costal cartilage and fifth rib. There was an opening in the pericardium and apex of the heart. The latter protruded. He sutured the pericar- dium with catgut and the patient recovered. {Deut. Med. Woch., August II, 1898.) Reed R. Harvey, during the year 1887, had a case of stab wound in the left chest over the apex of the heart. He removed a section of the sixth rib afid the clots in the peri- cardial sac and sutured the pericardium and cutaneous struct- ures. The patient is acting as a policeman in Shelby, Ohio. (Personal communication.) Dalton, H. C. (1891, September 6, Annals of Surgery), sutured the pericardium for a stab wound, with recovery. Resuscitation — There are numerous ways suggested to induce return of the heart's action. Among those most com- monly practised are pressure, manipulation, subjecting the heart to a saline solution, cold or hot air, needling, aspira- tion, electricity, and the exhibition of adrenalin. Pressure. — This may be accomplished by compressing the chest wall or diaphragm when the abdomen is open. Manipulation is done with the fingers or hand when the chest is open. A part or all of the heart may be held in the palm of the hand and gently pressed with each systole. If the opening in the pericardium is not sui^cient to permit of the entire heart being grasped in the palm of the hand, the apex alone may be grasped by the thumb, index, and second fingers and gently compressed with each systole, or about eighty times a minute. Saline solution. — The immersion of the heart in a normal salt solution has been known to stimulate the cardiac fibres to contraction. It may be injected into the pericardial sac through a hollow needle or it may be introduced with a syringe through a rent in the pericardium. Cold or hot air has also been known to stimulate the 154 THE SURGERY OF THE HEART heart's action when once it has become quiescent. The blowing of air with the mouth or bellows has, in a few in- stances, also stimulated cardiac action, when once it had ceased. Needling. — The introduction of a small needle into the wall of the heart has been shown to cause the heart to renew its contraction after it had ceased for several seconds. Aspiration. — Westbrook (New York Medical Record, 1882, Vol. II, page 705) abstracted blood from the right heart for simple distention and to excite a return of its action. Maag had a case of death from chloroform narcosis, but before the patient died he made use of the pressure method of resuscitation, i.e., manual compression of the heart and artificial respiration. For the latter purpose air was blown into the lungs through a tracheal cannula. Half an hour elapsed before they could perceive natural respiration. For one hour the breathing was deep and regular, the heart beats were powerful, seventy per minute. An hour later, the patient, apparently saved, was put to bed, although still unconscious. In a few minutes respiration ceased and could not be restored. The heart continued to beat for eight hours after, and then stopped suddenly; the temperature fell gradually during this time. Maag resorted to the pressure method in this case ten or fifteen minutes after all pulse and respiration had stopped; the patient was cold and cyanotic. Resuscitation was successful, even though the patient died. A personal communication from E. Lanphear states that he resuscitated a patient from chloroform narcosis by manual compression of the heart. The patient was brought to con- sciousness and was able to converse, but died one hour later. Electricity. — The negative pole of a faradic current ap- plied to any portion of the vagi will stimulate the heart's action. Muhlberg and Crile believe that adrenalin is a most powerful cardiac stimulant, in fact the most powerful of any CARDIORRHAPHY — CARDIOTOMY— HEART SUTURES I 55 known at the present time. (See Chapter on Experimental Heart.) Causes of Death — Primary. Shock, haemorrhage. Secondary. Carditis, endocarditis, pericarditis, pleuritis, pneumonitis, embolism (air or clot), abscess, aneurysm, ex- haustion. Primary shock is the term applied to that class of heart injuries which produce instant death without much if any loss of blood. Haemorrhage is the cause of death in the greater number of cases. Life may be maintained several hours after the heart has received a fatal injury. In such a case the proba- bilities are that the laceration is limited to the external sur- face of the heart. Haemorrhage may also result from an injury to a small branch of one or both of the coronary ar- teries or a small puncture through the endocardium, regard- less of the size of the opening on the external surface of the heart. Secondary carditis frequently results from lacerations or contusions and may be local or general, varying in degree of seriousness. Endocarditis occurs perhaps more frequently, and is many times associated with carditis. It may be the result of car- ditis or it may cause it. If there is endocarditis without in- jury to the endocardium, it is the result of carditis, but it more frequently occurs as the result of direct injury. Pericarditis is probably the most frequent complication, and it may follow cardiac injury of any degree, at any time, in a circumscribed or general way. If it is present at the time of operation, the pericardium should be left open and provided with a strip of gauze for drainage. In such cases the pericardium will become adherent to the heart. Pleuritis resulting in empyema is of frequent occurrence. The pleura may be involved without empyema. In either case inflammation of the pleura may be a complication with- 156 THE SURGERY OF THE HEART out the pleura having received direct injury. It may be cir- cumscribed or general. Pneumonitis is a serious complication, resulting from direct injury or secondary to injury to the heart. The left lung is more frequently involved than the right, and the extent of involvement may be of any degree. Embolism (air or clot) may be fatal at any time during convalescence. It is to be especially feared in all cases in which the injury has extended to the cavity of the heart; otherwise it is not likely to occur. Air entering the heart during the closure of a heart wound is not so much feared in later years. It is, however, to be considered and guarded against. Its entrance into the heart may cause immediate or subsequent death. It may enter the heart before the closure of the opening or it may enter subsequently, if the sutures should tear out or become ab- sorbed or break before union has been complete. Abscess may occur in the wall of the heart within the pericardial, pleural, or mediastinal space; wherever it may exist, free drainage should be resorted to. Aneurysm has been observed in the cicatrix of cardiac wounds. It may occur and terminate fatally at any time, or it may develop slowly and may or may not result in disso- lution. Exhaustion is usually due to one or more of these com- plications of any degree to that of fatal termination. The accompanying fifty-six cases of heart suture with twenty successes are a glowing tribute to the many achiev- ments already attained during the nineteenth century, and, coming as it does so near its close, one is led to believe that the twentieth century will not be far advanced before the problems of surgery of the heart will be determined and become fixed. That incisions, lacerations, and pvmcture of the heart from any cause will be successfully sutured, superficial ab- CARUIORRHAPIIY—CARDIOTOMY— HEART SUTURES I 57 scesses and cysts evacuated by incision, foreign bodies, clots, and pathogenic organisms removed from the wall or the cavi- ties of the heart, there can be but little doubt. Callender (1871) extracted a needle imbedded in the human heart, and Roswell Park (1877) unintentionally aspirated a myocardial abscess. These are probably the first recorded cases in which anything surgical has been done with the human heart. Farina (1896) reports the first recorded case in which sutures were applied for a traumatic opening in the cardiac wall, and, although the patient died on the fifth day from bronchopneumonia, much credit should be given the operator. The wound was made with a dagger entering just above the margin of the left sixth rib near the sternum. An open- ing one-fourth of an inch in length was made in the right ventricular wall. Three stitches were taken with silk. Cappelen (1896) records a case of stab wound of the heart through the fourth left intercostal space in the middle axillary line, inflicting a penetrating wound four-fifths of an inch in length, not into the left ventricle. The operation was done one hour later. Death ensued several days after, from pericarditis. A branch of the coronary artery had been accidentally cut during the operation, probably with the needle. Rehn (1896) also sutured a stab wound of the heart of a man twenty-two years old, the opening being in the right ventricle. The knife entered the fourth left intercostal space near the sternum. Three sutures were applied twenty-six hours after the injury. Although empyema developed, the patient recovered. This is the first recovery to follow sutur- ing the heart for injury. Parrozzani (1897) had the second case to end in recovery from heart suturing for a three-quarter inch incision in the left ventricle five hours after the injury. The knife entered 158 THE SURGERY OF THE HEART the seventh left intercostal space in the middle axillary line. No anaesthetic was given. Parrozzani again records a case in which suturing of a three-quarter inch puncture in the right ventricle was done through the third left intercostal space one-half hour after the injury. Death, on the second day, was due to a cut in the interventricular saeptum. No anaesthetic was given. The heart wound was firmly closed. Funna (1898) reports a stab wound under the left nipple, the weapon entering the apex of the heart, but not the cardiac cavity. Sutures were applied several hours after the injury. Empyema followed, but recovery took place. No anaesthetic was used. Parlavecchio (1898) mentions the case of a young man who walked a quarter of a mile with a V-shaped penetrating knife wound, three and one-half inches long, in the wall of the left ventricle, through the fifth left intercostal space. Eight hours after the injury the chest was opened and four interrupted silk sutures were applied. Chloroform narcosis was employed, and recovery was uneventful. Ninni (1898) reports the case of a man thirty years of age who, after receiving a knife wound in the left fifth intercostal space, walked two hundred steps with a wound in the anterior wall of the left ventricle near the apex twenty- five mm. in length. Without anaesthesia the chest was opened and the pleura incised, with the escape of much clotted blood. Two silk sutures were used to close the wound in the heart, and continuous sutures to close the pericardium. The patient died while the pleural cavity was being cleared of clots. Giordano (1898) records a case of an incision four-fifths of an inch in length in the left auricle in which he applied four stitches one-half hour after the injury. The external wound was in the second left intercostal space. No anaes- thetic was used. Death took place on the nineteenth day. Plate XIX. '^ X 440. Myoma. X IGO. Rhabdomyoma. (Chapter on Benign Tumors.) CARDIORRIIAPIIV— CARDIOTOMY — HEART SUTURES I 59 Empyema and abscess in the right lung were found, but the wound in the heart had completely united. Nicolai (1898) took four stitches in a wound of the right ventricle one and one-half hours after the injury. The ex- ternal wound was in the fourth left intercostal space, midway between the margin of the sternum and the nipple. Chloro- form was used. Death occurred twelve hours later. Tuzzi (1898) records a case in which there were two wounds of the heart, one penetrating and one non-penetrat- ing. The external wound w-as in the fourth left intercostal space. No chloroform was used, and death occurred on the twenty-second day from empyema and pericarditis. Longo (1898) records a case of injury through the fifth left intercostal space, two-fifths of an inch internal to the nipple, producing an opening in the left ventricle necessitat- ing three stitches. The operation was done at once without an anaesthetic. Death followed in fifteen minutes. Williams (1898) reports a discovery follownng the sutur- ing of a stab w^ound of the heart. (Da Costa, " Surgery," p. 240.) Ramoni (1898) applied four stitches in two wounds of the heart, one penetrating and one non-penetrating. The external wound was at the third left cartilage, four-fifths of an inch from the sternum. No anaesthetic was used. Re- covery followed. Marion (1899) sutured a gunshot wound in the heart, with death. Rosa (1899) was not sure that a stab wound of the left ventricle wall entered the cavity. He sutured a three-fifth inch incision without anaesthesia and with recovery. Horodimki (1899) sutured an incision one and one-half ctm. long in the right ventricle, with death. Maliszenski (1899) sutured a heart wound, with death. Alaliszenski (1899) sutured another heart wound, with a fatal result. l6o THE SURGERY OF THE HEART Bufnoir (1899) sutured a twenty-two calibre gunshot wound of the right ventricle. The ball entered the fifth left intercostal space. Death followed. The necropsy showed perforation of the ventricle, and the anterior opening only had been sutured. Pagenstecher (1899) records the case of a man seventeen years old in which he applied two stitches in a wound of the apex of the left ventricle, sixteen hours after the injury, without anaesthesia, the point of entrance being in the fourth left intercostal space, beneath the nipple. Recovery took place. Nanu (1900) applied two interrupted sutures in a wound of the right ventricle two ctm. long, the point of entrance being in the third left intercostal space, four ctm. from the edge of the sternum. Death occurred on the fifth day, from infection of the pericardium and pleura. Masseli (1900) sutured a wound of the left ventricle, near the apex, one and one-half hours after the injury. The ex- ternal wound was below and internal to the left nipple, cutting the fifth rib. The patient died twelve hours afterward. Fountain (1900) sutured a wound twelve mm. long in the left ventricle with continuous and interrupted catgut, six hours after the injury, using chloroform, with recovery. There were six external wounds with scissors between the third and seventh rib in the cardiac region. Nietert (1901) sutured a stab wound in the heart three- fourths of an inch long. Three silk sutures were used to close the wound in the right ventricle. Death occurred after twenty-five hours. Vaughan (1901) applied a continuous silk suture, seven stitches, in a w^ound of the left ventricle two and one-half ctm. long, forty-five minutes after the injur>'. Ether was used. Death of the patient took place on the table from haemorrhage at the time of the completion of the operation, from external wounds in fifth left costal cartilage divided. CARDIORRHAniY— CARDIOTOMY — HEART SUTURES l6l Nietert (1901) applied two sutures in a wound of the left ventricular wall. It was doubtful whether the cavity had been opened. Recovery took place. Zerlehner (1901) reports a case of a man who had been stabbed in both chest and abdomen. The chest wound pene- trated the heart. He sutured the incision in the wall of the left ventricle. The patient bled to death by reason of the five sutures being torn out almost immediately. The general condition of the patient was such that he would have un- doubtedly died even if the sutures had not given way. Ninni (1901) had a case of wound of the right auricle, the entrance being in the chest left of the sternum; the patient died in four days, from sepsis. Mignon and Sieur (1901) sutured a wound of the right ventricle; death followed. Fontan (1901) sutured a wound of the left ventricle with catgut. Empyema followed; its evacuation was made, fol- lowed by recovery. Brenner (1901) had a case of injury to the left of the sternum, near the sixth cartilage, the right ventricle being injured. The patient was operated upon on the following day. Death took place on the table. Degeneration of the heart muscle was found. Watten (1901) records a case in which the missile en- tered the fourth right intercostal space, injuring the right ventricle, producing a wound from three to four ctm. in length. The right pleura was wounded. Pneumothorax followed, but recovery took place. Lastaria (1901) had a case in w^hich the left ventricle was injured, and was sutured. Death occurred in a few days. Launay (1902) reports a case of a pistol ball entering the left ventricle, perforating both the anterior and posterior walls of the heart. He used catgut sutures in each wound, and recovery took place. l62 THE SURGERY OF THE HEART Raiisohoff (1902) had a case of non-penetrating pistol wound of the left ventricle. Death took place on the table. Stewart, G. D. (1902, personal communication), had a patient with an injury of the heart, which he sutured. It was followed by death. Nietert, H. L. (Surgery of the Heart, " American Journal of Surgery and Gynaecology, " St. Louis, 1902, xv, 1 51-153, "Philadelphia Medical Journal," 1902, ix, 790-793, i fig.) had a case in a male, aged 27, penetrating wound of left chest. A hurried examination showed an incision wound in the sixth interspace, a little to the right of the left papillary line ; super- ficial area of cardiac dulness was somewhat increased toward the left; there was absolute flatness posteriorly over the area normally occupied by the lower lobe of the left lung. A nor- mal vesicular murmur was heard over the entire right lung and upper portion of the left lung. The finger being intro- duced into the wound, it was found that the pericardium had been cut. The finger was then introduced through the incision in the pericardium and it was found that the heart also had been entered by the knife. In order further to explore the wound and ascertain its true nature a flap was made including the fifth and sixth ribs on the left side of the sternum. The outlines of the flap were as follows : The first incision was made along the lower border of the fourth rib, extending for two inches outward from the left border of the sternum. A second incision was made along the lower border of the sixth rib to a point about two inches to the left of the sternum. The outer extremities of the two incisions were united by a third incision. The fifth and sixth ribs were divided in the line of the outer wound, as were also the intercostal muscles and pleura. The entire flap, composed of skin, muscles and ribs, was forcibly pulled toward the right side, partly breaking the car- tilages near the sternum. (The flap was a modification of that devised by Rotter, and is fully described above.) Through this opening an excellent view could be obtained of the pericar- CARDIORRHAPHY— CARDIOTOMV — HEART SUTURES 163 clium and the cut in it. A cut about three-quarters of an inch in length was seen in the left ventricle, located far back. Two interrupted silk sutures were introduced by means of a highly curved gut needle. The wound was treated as an infected one and drains were introduced; one in pericardium back of the heart and the opening in the pericardium only partly closed; another drain was placed in the pleural cavity. The osteoplas- tic flap was then allowed to fall back into position and sutured, except at point of drain. Patient was unconscious for several days after the operation. During this time he was given frequent hypodermic injections of strychnine and whis- key. The drains were removed on the fourth day. Patient made an uninterrupted recovery. The conclusions are: i. That gentle manipulation may be applied without producing shock; 2, that the introduction of the suture produces but a slight irregularity in the heart's action; 3, that heart wounds heal rapidly; 4, intrapericardial pressure is increased even if haemorrhage occurs during diastole alone; 5, that all heart wounds in which there is danger of fatal haemorrhage should be sutured; 6, if the wound does not involve the pleura the ex- trapleural route should be employed as described above; 7, if the pleura has been injured the intrapleural method should be employed, and the flap devised by Rotter is the best; 8, al- though it is advisable for the surgeon to familiarize himself with the methods of operation and the flaps devised by the dif- ferent operators a thorough knowledge of the anatomy of the region is most essential, and each operator should modify the flaps as best suits his case. REPORTS OF CASES OF SUCCESSFUL SUTURING BY DIFFERENT OPER- ATORS WITH VARIOUS TERMINATIONS, AND THE CONCLUSIONS By L. L. Hill, M.D., surgeon to the Hill Infirmary, Mont- gomery, Alabama. Personal communication. Henry Myrick, a negro, thirteen years of age, of rather delicate appearance, was stabbed at five o'clock on Sunday 164 THE SURGERY OF THE HEART afternoon, September 14, 1902. About six hours after the injury Drs. Parker and Wilkerson were called, and, perceiv- ing the nature of the case, advised that I should be sent for, and upon my arrival I urged an immediate operation. To this the parents readily consented, and I was assisted in the operation by Drs. Wilkerson, Parker, Michel, R. S. Hill, Robinson, and Washington. The knife blade entered the fifth intercostal space, about a quarter of an inch to the right of the left nipple, and, penetrating the apex of the heart, passed into the left ventricle. The wound was about three- eighths of an inch in length, and from it came a stream of blood at every systole. There was no external bleeding, but his general condition was very unfavorable. The radial pulse was almost imperceptible, and the heart sounds were heard with difficulty. There was a triangular-shaped area of dul- ness. He had dyspnoea and was very restless. His extremi- ties were cold, as were his lips and nose. When aroused, he answered questions intelligently, though his countenance showed great distress. Securing two lamps, I removed the boy from his bed to a table at one o'clock at night, eight hours after the stabbing, and proceeded to cleanse the field of the operation and place the patient in as favorable a condi- tion as my surroundings in the negro cabin would admit. Commencing an incision about five-eighths of an inch from the left border of the sternum, I carried it along the third rib for four inches. A second incision was started at the same distance from the sternum and carried along the sixth rib for four inches. A vertical incision along the anterior axillary line connected them. The third, fourth, and fifth ribs were cut through with the pleura. The musculo-osseous flap was raised, with the cartilages of the ribs acting as hinges. There was no blood in the pleural cavity, but the pericardium was enormously distended. I enlarged the open- ing in the pericardium to a distance of two and one-half inches and evacuated about ten ounces of blood. The pulse im- ACRDIORRIIAPIIY — CARDIOTOMY — HEART SUTURES 165 mediately improved, and this was commented upon by Dr. L. D. Robinson, who so successfully and skilfully admin- istered the chloroform. I had my brother, Dr. S. Hill, pass his hand into the pericardial sac and bring the heart up- ward, and at the same time steady it sufficiently for me to pass a catgut suture through the centre of the wound in the heart and control the hemorrhage. I cleansed the peri- cardial sac with a saline solution and closed the opening in it with seven interrupted catgut sutures. The pleural cavity was also cleansed with a saline solution and drained with iodoform gauze. The musculo-osseous flap was brought down and stitched in position. The operation lasted forty- five minutes. The patient's pulse, on reaching his bed, was 145 and respiration 56. I injected strychnine hypodermically and employed hypodermoclysis and autotransfusion. The following morning, September 15, the boy's pulse was 130 and temperature 102°, and he was slightly delirious. On September 16 there was but slight change in the tempera- ture and pulse, though the delirium was much worse. On September 17 he commenced to improve, and his recovery has been uninterrupted. I allowed him to sit up on the fif- teenth day. Dr. E. C. Parker, who assisted me in the subsequent management of the case, examined the urine fre- quently, but was o-nly able once to find a trace of albumin. Conclusions — First. — Any operation which reduces the mortality of a given injury from ninety per cent, to about six- ty-two per cent., is entitled to a permanent place in surgery, and every wound of the heart should be operated on imme- diately. Second. — Whenever the location of the external wound and the attending symptoms cause suspicion of a wound of the heart, it is the duty of the surgeon to determine the nature of the injury by an exploratory operation, as is recom- mended by Professor Vaughan. Third. — Unless the patient is unconscious, and corneal l66 THE SURGERY OF THE HEART reflex abolished, as in Pagenstecher's case, an anaesthetic should be given, and preferably chloroform. Strugghng is apt to produce a detachment of a clot and renew the hemor- rhage, as occurred in Parlavecchio's patient. Fourth. — Never probe the wound, as serious injury may be inflicted upon the myocardium. Fifth. — Rotter's operation renders access to the heart ex- tremely easy, and should be generally adopted. Sixth. — Steady the heart before attempting to suture it either by carrying the hand under the organ and lifting it up, or, if the hole is not large enough, introduce the little finger, as Parrozzani did, which will serve the double purpose of stopping the bleeding and facilitating the passage of the stitches. Seventh. — Catgut sutures should be used, as wounds of the heart heal in a remarkably short time. The sutures should be interrupted, introduced and tied during diastole, and not involve the endocardium, and as few as possible should be passed commensurate with safety against leakage, as they cause a degeneration of the muscular fibre with its tendency to dilatation and rupture. Eighth. — In cleansing the pericardium it should be sponged out, and no fluid poured into the sac. Ninth. — It hardly seems necessary to accentuate the fact of the necessity of perfect cleanliness in these operations whenever the urgency of the case does not require instant intervention, as in the patients of Longo and Ninni. The wound in the pericardium should be closed, and should symptoms of compression arise, reopen the wound and drain as Rehn did. By Louis Rassieur, M.D. Personal communication. Edward Spilker, white, single, aged nineteen years, nativ- ity, St. Louis, Mo., shot himself with suicidal intent on Sun- day, January i8, 1903, at 2.45 p.m. "A Christian Scientist" Plate XX. X 80. Polypus. (Chapter on Benign Tumors.) CARDIORRIIAPHY— CARDIOTOMY — HEART SUTURES 1 67 saw him and probed the wound with a lead pencil. A regu- lar physician was then called in. The latter pronounced the wound necessarily fatal, and advised the patient's transfer to the St. Louis City Hospital. When he arrived, at 3.45 p. m., his pulse was bad, his abdomen board-like. A powder-burned pistol wound was in the fourth interspace, just below and internal to the left nip- ple. The chest showed, on physical examination, signs of a slight hsemothorax. There were none of the many symptoms so clearly classi- fied by the various writers which are pathognomonic of gun- shot wound of the heart. The patient looked pale and was very indisposed. The senior physician, who first saw the case, in fact, re- ported it to me as one of gunshot wound of the chest, with the bullet ranging down toward the peritoneal cavity, not at all divining the fact that the bullet had struck not only the heart, but the left lung also. I ordered the patient prepared for operation. The preparation, et csetera, took about two hours. During this time he bled about a pint and a half from the gunshot wound. When the patient was placed on the table for operation, he presented a different picture. He was now well-nigh de- pleted, almost indifferent, and covered with profuse perspira- tion. He was anaesthetized with chloroform. The operation began at 5.45 p. m. Operation. — An incision three inches long, parallel to the left papillary line, was made, extending through the gunshot wound. One inch of the fourth and fifth ribs was resected, one-half inch of the cartilaginous and one-half Inch of the bony portion of the respective ribs. The intercostal vessels were secured by silk ligatures. The chest was now full of blood. I turned the patient on his belly to let the blood run out of the chest. Then I turned him on his back, and found r68 THE SURGERY OF THE HEART on examination a hole in the pericardium, which was also powder-stained. I enlarged the hole two inches. The heart-sac was full of blood. I mopped out the heart-sac with sterile gauze, and with the left hand drew the heart forward, grasping the heart at the apex. There was a ragged laceration of the wall of the left ventricle midway between the base and the apex. The laceration bled freely and was half an inch wide, three- eighths of an inch deep, and an inch and a half long. Three silk sutures, of medium-sized silk, were introduced into the heart muscle. The approximation was ideal. The haemor- rhage from the heart muscle ceased. On further examination of the pericardium, the wound of exit was found in the bottom of the sac. I washed the sac with physiological saline solution. I then cut out the burned portion of the sac and now approximated the sac in- cision with eight medium-sized silk sutures, thus using no drainage in the pericardium. I now drew forth the lower lobe of the left lung. The lower lobe had been perforated by the bullet and was bleed- ing freely. About a square inch and a half of the lower lobe was infiltrated with extravasated blood. I raised this portion of the lung, and then tied around it a silk ligature of the heaviest silk. Thus the lower portion of the lower left lobe was ligated en masse; treated as if it were but a single vessel. The ligature was drawn very tight, crushing the lung tissue. The part beyond the ligature was cut away. In this way the bleeding of the lung was disposed of in three-quarters of a minute. During the operation I had the median flap of the chest wound raised with a retractor. While sewing the heart I held it with my left hand against the median side of the chest, and introduced my silk sutures w^ith a gut needle. I used a Halsted artery forceps as a needle holder. I now turned the patient on his belly to rid the chest of the blood. CARDIORRHAPHY — CARDIOTOMY — HEART SUTURES 169 Now I rolled him on his back. I introduced a single strand of gauze into the left pleural cavity as a drain. The gauze in the mouth of the pleural wound had an additional motive, in that it kept the mouth of the wound open and permitted filtered air to rush into the pleural cavity, thus forming an air cushion or splint about the left lung, preventing the ex- pansion of the lung and the occurrence of pneumonia. The bullet was somewhere in the muscles of the back. The pectoral muscles were approximated with medium-sized silk, the skin with silkworm gut. The operation ended at 6.45 P.M.; duration, fifty-five minutes; anaesthesia with chloro- form (Squibb's). No stimulants were given save a hypodermoclysis of physiological saline solution, 250 c.c, just before the opera- tion. Post-Operative Course. — When the patient was put to bed his chart was 99.2° F. ; respiration, 28; pulse, 100. He com- plained of severe incessant pain over the region of the heart. The temperature, respiration, and pulse grew rapidly higher. The highest point was reached the next morning at 3 a.m. (January 19, 1903). Temperature, 103.4° F. ; respiration, 36; pulse, 152. Then it receded. At 9 p. m.^ temperature, 100.2° ; respiration, 38; pulse, 132. January 20. — 102.8° ; respiration, 30; pulse, 128. Severe heart pain continued. At 6 p. m. the patient got up and walked sixty feet, and went to bed again. His walk did not harm him. He wished for a great deal of nourishment. He was given four ounces of water, milk, or beef-tea hourly if awake. (For twenty-four hours after the operation he was fed entirely per rectum.) January 21. — Temperature, 101°; respiration, 36; pulse, 106. Resting easier. Drain removed from the pleural cavity, none returned. A slight amount of bloody fluid (three ounces) came from the chest on turning the patient on his ab- domen. I/O THE SURGERY OF THE HEART Jwmary 22. — Temperature 100° ; respiration, 33 ; pulse, 106. Continues in fine condition. A slight systolic murmur heard best over the base of the heart; no physical signs of pneumonia. January 2^. — Temperature 99.4°; respiration, 36; pulse, 106. Continues in fine condition. Patient is dressed once every two days. He sleeps well. He receives five saline enemata every twenty-four hours and an occasional hypodermic of morphine sulphate, grain one- sixth. Up to the present time he has received nine-sixths of a grain of morphine sulphate. Absolutely no other form of medicines and no other stim.ulants, not even alcoholic, have been resorted to. The morphine was the only drug used. (This is the third case under my observation. I saw Dr. Neitert's two cases daily.) Analysis of Fifty-six Cases of Heart Suture Character of the Wound. — The majority of the wounds were single and non-penetrating. However the percentage of recoveries from penetrating wounds that had been sutured was quite as large as from those of non-penetrating wounds. Probably two-thirds of the wounds of the heart that had been sutured had been produced by dagger-like instruments; some accidental, some with suicidal, and still more with mur- derous intent. The greater number of subjects of heart injuries operated upon, and the surgeons operating upon them, have been Italians. This probably accounts for the frequency of wounds, stiletto-like in character. The mortality is greater in gunshot wounds. In one case operated upon death was due to the failure of the operator to close the endocardial opening with the external opening in the heart. This is one of the greatest dangers, and should, therefore, be carefully guarded against. CARDIORRHAPIIY—CARDIOTOMY— HEART SUTURES 17I AnccstJictic. — Surgical anaesthesia by any means is not al- ways necessary to suture the heart. Many such operations have been done without it. The greatest judgment should be exercised in the use of chloroform, ether, or nitrous oxide. Both ether and chloroform have been used, and, again, the operation has been frequently done without their use, some- times while the patient was unconscious and sometimes while he was conscious. Many of these injuries will not admit of sufificient time to produce artificial unconsciousness, others will, however, especially in non-penetrating wounds of the heart, a condi- tion that cannot be determined without opening the peri- cardium. External Location of the Wound. — This may be at any point upon the chest, abdomen, or neck, in any of the soft or bony tissues. About eighty-five per cent of those operated upon have been on the left chest, ranging from the axillary line to the anterior median line, from the third to the seventh intercostal space. The fourth and fifth intercostal spaces are the most frequent locations of entrance. Time of Operation After Injury. — This depends upon en- vironments and the aggressiveness of the attendants in whose hands the life of the patient is intrusted. In two or three instances the operation was done immediately, in fifteen to thirty minutes, and in one as late as twenty-four hours after the injury. The wounds have been non-penetrating in the majority of cases operated upon late. In a few there was a very super- ficial non-penetrating wound with severance of one or both of the coronary vessels, vein and artery. Accidents During Operation. — In one a branch of the cor- onary artery was severed, probably with the needle while suturing. In another an injured sasptum was overlooked, and in still another a perforation of the ventricle, posterior, was not closed with the external opening in the heart. 172 THE SURGERY OF THE HEART « Kinds of Suture. — Silk and catgut have been the only material employed. Interrupted silk sutures have been most frequently employed, from one to seven in number in each individual case. Continuous sutures were used in but two or three cases. Catgut has been very infrequently employed. In one case in particular both interrupted and continuous sutures of this material were employed, with recovery of the patient. Deaths and Duration of Life After Operation. — Several have expired on the table during or at the completion of the operation; others from fifteen minutes to several days after the operation. Unconsciousness prevailed in a few at the time of operation, so that anaesthetics w^ere not required for the operation. Causes of Death. — Exhaustion from haemorrhage or in- fection is most common. Hemorrhage is the more common. It may result in instant death or it may be slow and gradual. Death may occur from loss of blood resulting from a pene- trating wound of the heart, its great vessels, the mammary, in- tercostal, pulmonary, or coronary arteries, one or all, singly or combined. Empyema, pleurisy, bronchopneumonia, carditis, and peri- carditis each has contributed to the causation of death in this class of cases. Mortality. — Fifty-six operations: twenty recoveries.. Age Most Favorable for Reeovcry. — From twenty to for- ty-five the blood-pressure is comparatively high, and the stress of blood-pressure on the arterial walls causes an in- crease in diameter of the large arteries. There is also a progressive increase in the size of the heart, year by year, at a nearly uniform rate. But after forty-five, although the arteries continue to increase in size, there is a fall in the blood- pressure. At the same time, almost suddenly, the heart be- gins to diminish in size. The widening of the arterial trunks and fall of blood-pressure, the reduction of mechanical stress Plate XXI. rfe^.. X 105. Sarcoma, (Giant Cell). X 3G0. Sarcom.v, (Spindle Cell), (Chapter on Malignant Tnmors.) CARDIORRHAPHY — CARDIOTOMY— HEART SUTURES I 73 from bodily relaxation, the loss of tone in the vasomotor mechanism of the splanchnic area, are all factors in produc- ing this diminution in the size of the heart. Any chronic disease which usually afflicts men at this age may perhaps have some influence in this, too. There is also a change in the quality of the blood. It becomes more venous. At sixty- five a large portion of the capillary network becomes obso- lete because of lowered metabolic and functional energy of the tissues caused by this decline of circulatory energy and the effects of age on the cell contents of the body. These changes increase the peripheral resistance, which causes a rise in the blood-pressure. This in turn produces an increase in the size of the heart, so that the heart at fifty- five is as large as it was at forty-five. At the same time the haemoglobin value of the blood becomes higher. There is no reason why the heart should not remain structurally sound until the most advanced years of life; that is, there is no physiological reason for structural degeneration unless there is some disease present; hence all cardiac and vascular dam- age that occurs in the second half of life must be produced by physical stress caused by sudden and violent exertions or from some severe laborious occupation. Care must be taken to see that men of middle age who are advised to take physical exercise do not overdo it. Depressing emotions originating in worry, anxiety, etc., no doubt also are factors in producing cardiac troubles. Then, again, nervous depressions which may cause the foregoing are due to disease, such as gout, influenza, malaria, tubercu- losis, and syphilis. Overwork, worry, and nervous troubles are often held responsible for causing cardiac failure, when in fact the true cause is alcohol. All disturbances of metabolism in middle life are apt to cause heart troubles, especially in the so-called middle and higher classes of society. 174 THE SURGERY OF THE HEART BIBLIOGRAPHY. Farina, Centralblatt f. Chir., 1896, p. 1224. Cappelen, Deutsche Med. Woch., 1896, p. 186. Rhen, Journal Expcr. Med., XIV, No. 5-6, p. 488. Parrozzani, Bull. d. m. Acad. Med. de Doma, 1897-98, XXIII. , 243, also Semaine Med., 1897, No. 23. Terrier and Reymond^ Paris, 1898. Parlavicchio, Riforma Medica, 1898. Giordano, Riforma Medica, 1898; Sept. 9th and loth. Se- maine Medicale, 1898, p. 407. NiNNi, Giomata Internan. d. Sc. Med., 1899, No. L. Pagenstecher, Deutsche Med. Woch., 1899, No. 31. Geraldini, Roma, 1899. Maselli^ Sup pi. al Policlin Roma, 1899- 1900, VI., 1345- 1352. Rotter^ Verhandlund. Gesellsch. Dciitsch Natiirf. u. Aertze, 1899, Leipz., 1900, LXXL, pt. 22, hlfte, 541 Le Fort, R., Echo Medical dii Nord, Lille, 1900, IV, 495- 497- ToRNU, A., Gazz. Med. di Roma, 1900, XXVI, 225-237; 260- 266; 10 fig. Terrier et Reymond, Rev. de Chir., Paris, 1900, XXII, 473-494; 6 fig. Maselli, E., Bidl. d. Soc. Lancisiana d. Osp. di Roma, 1900, XX, 164. FoNTAN, J., Bull, et Mem. Soc. d. Chir., Paris, iqoo, XXVI, 492-496. Nobles, N. T. B., Medical Century, New York and Chicago, 1900, VIII, 225-228. Stern, C., Miinch. Medidn. Woch. 1900, XLVII, 424-426. Reymond, E., Rev. de Chir., Paris, 1900, XX, pt. 2, 473, 494. Tornu, a., Gaz::. Med. di Roma, XXVI, 7, 29, 122, 169, 225, 260. Hill, L. L., Med. Rec, New York, 1900, LVIII, 921-924. CARDIORRHAPIIY— CARDIOTOiMY — HEART SUTURES I 75 Walcker, O., Deutsche scitschr. f. Chir., Leipzig:, igoo, LVIII, 105-111. Watten^ J., Gaz. lek. Warszawa, 1900, XX, 963-970. Stuparich, Wien. Med. Presse, 1900, XLI, 2413-15. Carnabel^ Bull, et Mem. Soc. de Chir. de B nearest j 1900, III, 144-148. Giordano^ E., Napoli, 1900. FuNNA, Medical News, December 7, 1901, Vol. LXXIX, No. 23- NicoLAi_, Medical News, December 7, 1901, No. 23. Tuzzi, Medical News, December 7, 1901, No. 23. LoNGO^ Medical News, December 7, 1901, No. 23. Williams^ De Costa's Surgery, p. 240. RoMANi^ Medical Nezvs, December 7, 1901, No. 23. Marion_, Medical News, December 7, 1901, No. 23. RosA^ Medical News, December 7, 1901, No. 23. HoRODYMSKi, Medical News, December 7, 1901, No. 23. Maliszenski^ Medical News, December 7, 1901, No. 23. BuFNOiNj Medical News, December 7, 1901, No. 23. Nanu^ Medical Nezvs, December 7, 1901, No. 23. Maselli^ Medical News, December 7, 1901, No. 23. Fountain^ Medical Nezvs, December 7, 1901, No. 23. NiETERT_, American Medicine, Volume i, No. 4, 1901, p. 149. Vaughn, Medical Nezvs, December 7, 1901, No. 23. NiETERTj Medical Nezvs, December 7, 1901, No. 23. Zerlehner, Wiener Klin. Woch., XIV, Jahrg. No. 11, March 14, 1901. Last ARIA, Riforma Med., Roma, 1901, XVII, pt. i, 808, 818,831. MiGNON ET SiEUR, Bidl. ct Mem. Soc. de Chir., Paris, XXVII, 422-426. Manine-Hitou, Bordeaux, 1901, p. 93. Francois- Jean-Marie, Rosa, Siippl. il Policlin., Roma, 1901, VII, 449-54- Pagenstecher, Deutsche Med. Woch., 1901, XXVII, 56. Wayenburg, Gen, Nederl. tijdschr. v Geneesk Amst., 1901. 1/6 THE SURGERY OF THE HEART GiLLAVRY, 2 r. XXXVI, d. 1., 1249-1258. BouGLE, ]., Bull, et Mem. Soc. d'Anat., Paris, 1901. Ill, 122- 125, fig. i. FoNCK U. Praun, Deutsche Med. IVoch., Leipzig u. Berlin, 1901, XXVII, 374-375; 2 fig. Nanu G., XIII Cong. Internat. de Med., Sect, de Chir. Gen., 1900, Paris, 1901, Compt. Rend., 602-3. ViLLAR^ F., Arch. Prov., de Chir., Paris, 1901, X, 614-631. Manara, L., Clin. Chir., Milano, 1901, IX, 213-219. ViGOT, Annie Med. de Caen, 1901, XXVI, 69-71. Mauclaire, Independ. Medical, Paris, 1901, VII, 9. Nanu, G., Un cas de plaie du coeur traite par la suture. XIII Congres International de Medecine, Section de Chirurgie, 1900. Paris, 1901. Compt. rend., 602-603. Lastaria, F., Su di un caso di sutura cardiaca. Ri forma Med- ical, Roma, 1 90 1, I, 808. Manara, L., La diagnosi e la prognosi delle ferite del cuore. (Riv. sintet.) Clinic Chirurg., Milano, 1901, IX, 213- 219. Wayneburg, C. v. en Gillavry H. Hersentumor operatic gene- zing. Nederl. Tijdschr. r. Geneesk, Amsterdam, 1901, 2 R. XXXVI, d. I, 1249-1258. Pagenstecher, Weiterer beitrag zur Herzchirurgie die unter- bindung der verletzten arteria coronair. Deutsche medi- zinische zvochenschrift, Leipzig u. Berlin, 1901. XXVII, 5^7- ViLL.\R, F., La suture des plaies du coeur, etude experimentale technique operatoire, phenomenes observes pendant I'in- tervention. Paris, I. B. S., 1901, 20 p. MiGNON ET SiEUR, Plaic du ventricule du coeur droit par coup de canif (tentative de suicide au cours d'une pneumonic grippale). Suture de la plaie ventriculaire ; mort brusque une heure et demie apres I'intervention. Bulletin et Me- moire Societe de Chirurgie de Paris, 1901, XXVII, 422- 426. BouGLE, J., Plaie du coeur par balle de revolver, suture du CARDIORRHAPHY— CARDIOTOMY — HEART SUTURES \'J^ coeur et de pericarde, hemothorax par blessure du hile pulmonaire; mort. Bulletin et Memoire Societe d'Ana- tomie de Paris, 1901, 6 s, III, 122-125; ^ fig- FoNCK, u Praum. Todtliche Stichwunde des Herzens bei ma- kroskopisch Blutfrei gebleibener Waffe. Deutsche Med. Woch., Leipzig u. Berlin, 1901, XXVII, 374-375; 2 figs. Lannelongue, Observations a propos de la note de Chapot- Prevost sur une operation d'ectocardie faite en 1888, et suivie de succes. Compt. Rendus Acad. d. Sc, Paris, 1901, CXXXII, 225. Manine-Hitou, F. J. M. De la suture des plaies du cceur {Manuel operatoire) , Bordeaux, 1901, No. 40; 93 p. Zulehner^ H. Zur Herznaht. Wiener Klinische Wochen- schrift, 1 90 1, XIV, 263-264. Rosa U. Intorno alia tecnica operativa nei traumi cardiaci. Suppl. il Policlin, Roma, 1901, VII, 449-454. Villar, F. La suture des plaies du coeur, etude experimentale technique, operatoire, phenomenes observes pendant I'in- tervention, Archiv. Provincial de Chirurgie, Paris, 1901, X, 614-631. Terrier^ D., Lancet, London, England, October 25, 1902, p. 1099. Mauclaire, Bull, et Mem. Soc. d'Anat., Paris, 1902, IV, 245- -274, 8 fig. Leuf, Medical Council, Philadelphia, Pa., June, 1902, p. 209. Berard and Viannay^ Presse Medicate, Paris, June 7, 1902, P- 543- Fontan; J., Bidl. Acad, de Med., Paris, 1902, XLVII, 381- 89. Cahen, F., Miinch. Med. Woch., 1902, XLIX, 444-46. NiETERT, H. L., Philadelphia Medical Journal, 1902, IX, 790-793; I fig. Shaw^ L. E., Lancet, London, 1902, 1, 619. Hill, L. L., Indian Medical Record, Calcutta, 1902, XXII, 195-201. NiETERT H. L., American Journal Surg, and Gynec, St. Louis, 1902, XV, 151-153- 178 THE SURGERY OF THE HEART Cowan, J., Glasgozv Medical Journal, 1902, LVII, 260-275, 2 fig- ViLLAR, F., Ca^. hebd. d. Sc. Med. de Bordeaux, 1902, XXIII, 158-160. Brunton, L., Rev. de Med. y Chir. de la Habana, 1902, VII, 223-225. Stewart, G. D., 1902, Personal communication. ViLLAR, F. A propos du traitement chiriirgical dii retrecisse- ment mitral. Gacette Hehdomadaire d. soc. Medecine de Bordeaux, 1902, XXIII, 158-160. FoNTAiN, J. Contribution a la chirurgie du coeur (Rap. par M. Le Dentu). Bulletin Acadcmie de Medecine, Paris, 1902, XLVII, 381-389. Shaw, L. E. Surgical operations for mitral stenosis. Lan- cet, London, 1902, I, 619. Hill, L. L. Wounds of the heart, with a report of seventeen cases of heart suture, Indian Medical Record, Calcutta, 1902, XXII, 195-201. Cahen F., Zur chirurgischen behandlung des Kardiospasmus, . Miinchen. Medidnische Wochcnsckrift, 1901, XLIX, 444-446. Terrier, F., et Raymond, E., De la cardiorraphie, Presse Medicate, Paris, 1902, II, 1011-1014; 10 gs. Terrier, F., et Raymond, E.^ Chirurgie du coeur et du peri- carde, Assoc Franc, de Chirurgie Proc.-verb, Coulom- miers, 1902, I, 1777. Mauclaire, Ecrasement antero-posterieur du thorax, contu- sion du coeur, exploration du pericarde et du coeur par la voie diaphragmatique, Bulletin et Memoire, Socicte d' Anatomic de Paris, 1902, IV, 245-274; 8 figs. Launay, Plaie double du coeur par balle (ventricule gauche) suture, guerison (rap. par M. Peyrot), Bulletin Academic de Medecine, Paris, 1902, XLVIII, 185-188. McLaughlin, 1903, Personal communication. Rassieur, 1903, Personal communication. CHAPTER VIII CARDIAC ANEURYSM Aneurysm of the heart may involve any portion, or the whole, of the cardiac wall, the left ventricle and upper portion of the interventricular sseptum being most frequently involved. The causes are those which produce aneurysm in any part of the arterial system. Heart strain and syphilis are the most frequent, but in some cases fatty degeneration may be a prominent causative factor. There are no definite symptoms by which cardiac aneurysm may be recognized, nor is there any curative treatment. Lit- tle indeed can be accomplished in the way of palliation. Historical (1843-1903). — In 1843 Craig published his ob- servations and reported cases, illustrating the false consecutive aneurysm of the heart. Billingham (1850) reported a case of aneurysm in the apex of the left ventricle, followed by pericar- ditis. Bristowe (1853), Elliott (1857), Habershon (1862), Arnott (1868) and Girdlestone (1869), all report cases of an- eurysm of the left ventricle. In the case of Arnott there was partial ossification of the heart-wall, winding around the root of the aorta. Gore (1872) reported an aneurysmal tumor of the aorta forming in the walls of the left ventricle. Barlowe (1875) mentions an aneurysm in the base of the left ventricle, and Janeway (1875) ^ double one in the same cavity. Hughes (1883), Allen (1883), Handford (1885), Haig (1885), and Sharkey (1885), each reported cases. In Sharkey's case there was also an aneurysm of the aorta. 179 l80 THE SURGERY OF THE HEART In 1888 Yonge reported a case simulating aneurysm of the descending aorta. In 1898 Sangree had a case of aneurysm of the left ventricle, and Burgess in the same year, one terminating in sudden death. Georgiades (1894) mentions a case in a man sixty-five years of age, in whom there was found an aneurysm about the size of a walnut, at the apex of the left ventricle. Hewett (1849) reported an aneurysmal dilatation of the left auricle, with thickening and contracting of the left auriculo- ventricular opening. Dawes (1875) reported a case of aneurysm of the base of the pulmonary artery. Irwine (1878) mentioned a case of displacement of the aortic valve by an aneurysm in the ventricular sseptum. Newcomb (1884) reported a case in which all of the signs and symptoms of aortic aneurysm were simulated by an enormously dilated heart. Williams (1890) reported an aneurysm of the pulmonary artery. In 1892 Hebb gives a case of atheroma of the pul- monary artery, and Kidd an emboHc aneurysm of the pul- monary artery with aortitis, pulmonary endarteritis, and patent ductus arteriosus. In 1895 GafTon records a case of aneurysm of the coronary artery due to its obliteration, and Claude an aneurysm in a case of obliteration of the anterior coronary artery. Turney (1896) reports a case of intra-pericardial aneurysm of the aorta. Callett and Steele ( 1898) report a case of aneur- ysm of the right pulmonary aortic sinus of Valsalva, with rupture. Salvilli (1885) reports a case of aneurysm of the inter- ventricular saeptum, and Taylor (1886), Maguire (1886). Pert (1889), Northup (1888), and Klein (1889), each mention cases of like character. Plate XXII. JS(L X 270. Sarcoma, (Small Round Cell), (Chapter on Malignant Tumors.) CARDIAC ANEURYSM l8l BIBLIOGRAPHY Thurman, Med. Chir. Trans., 1838. Craigie^ Edinb. Med. and Surg. Jour., 1843, LIX, 356-399. Peacock,, Edin. Med. Journal, 1846. Hewett^ p. G., Tr. Path. Soc, London, 1849-50, II, 193. Bellingham, O. B., Dublin Press, 1850, XXIII, 323. Ord^ Obstructive disease of the aortic valve, dependent on mal- formation ; small aneurysm in the ventricular saeptum. Tr. Path. Soc, London, 1850-52, III, 287. Jackson, True aneurysm of the heart. Extr. Rec. Bost. Soc. M. Improv., 1851-53, I, 64. Also Am. Jour. Med. Sc, Philadelphia, 1850, n.s., XIX, 368. Bristowe, Tr. Path. Soc, Lond., 1853-54, V, 93-95. Elliott, New York Med. Journal, 1857, 3, 8, II, 113. Also Med. and Surg. Reporter, Burlington, N. J., 1857, X, 21. Habershon, Lancet, London, 1861, II, 401. BowDiTCH, H. J., Extr. Rec. Bost. Soc. M. Improv. (1859- 61) 1862, IV (Suppl.), 245-249. Also Bost. Med. and Surg. Jour., 1861, LXV, 361-364. Francis, C. R., Case of aneurysm of the heart with syphilitic deposit. Indian Ann. Med. Soc., Calcutta, 1865, No. XIX, 319-324- Bell, A. N., Aneurysm of the heart. Tr. M. Soc. County Kings, Brooklyn, 1865, II, 45. Peloit, Des anevrysmes du coeur, 1867. Arnott, Tr. Path. Soc, London, 1868, XIX, 149-152; i pi. Girdlestone, Australias. Medical Journal, Melbourne, 1869, XIV, 166. Abbot, S. L., Two cases of aneurysm of the heart. Boston Med. and Surg. Jour., 1872, LXXXVII, 418. Gore, A. A., Lancet, London, 1872, II, 630. Goodfellow, S. J., Aneurysmal pouch proceeding from the ventricle of the heart, close to the attachment of one of the semilunar valves. Tr. Path. Soc, London. 1872, XXIII, 53. 1 82 THE SURGERY OF THE HEART Barlow, T., Tr. Path. Soc, London, 1875, XXVI, 65-67. Bentley, Aneurysm of the heart. Pacific Med. and Surg. Jour., San Francisco, 1875, XVI, 279. Dawse, T. S., Tr. Path. Soc, London, 1875, XXVI, 28. Janeway, New York Med. Journal, 1875, XXI, 54. Irvine, J. P., Tr. Path. Soc, London, 1878, XXIX, 47-49- Bell, Lancet, London, 1878, I, y2^. Talamon, Bull. Soc. Anat., 1879. EvART, Path. Society, London, 1880. Peabody, New York Aledical Society, 1881. Ingals, Aneurysm of the Heart. Med. Rec, New York, 1881, XX, 313-315- Laurand, G., Anevrysme, valvule mitrale, embolic de la cru- rale. Bidl. Soc. Anat., Paris, 1881, LVI, 425-426. MacLeod, N., A movable clot in the rigfht auricle. Edinb. Med. Jour., 1882-83, XX VIII, 696. Dulaceska, G., Aneurysma cordis partialis chronica. Gyog- yasj^at, Budapest, 1883, XXIII, 145-149. Legg, Wickham, Bradshawe lecture, 1883. Turner, Path. Society, London, 1883. Balzer, F., Anevrysme miliares du pericarde chez un syphil- itique. Arch. d. Pliys. Norm, et Path., Paris, 1883, II, 93-95- Ferguson, Aneurysmal dilatation of the heart and mitral ste- nosis, fibroid induration. Med. Rec, New York, 1883, XXIV, 75. Schmidt, H. D., The pathological anatomy of an aneurysm of the heart. New Orleans Med. and Surg. Jour., 1883-84, XI, 333-342 ; I pi. ^ Durand, p. E., Des anevrysmes des sinus de Valsalva a deve- loppement intra-cardiaque. Lyon, 1883. Hughes, W. E., Philadelphia Med. Times, 1883-84, XIV, 439-838. FouLis, J., On a case of patent ductus arteriosus with aneurysm of the pulmonary artery. Tr. Med. Chir. Soc, Edin- burgh, 1883-84, U.S., Ill, 156-175. CARDIAC ANEURYSM 183 Senise, T., Un case di dilatazione aneurismatica del ctiore. Ann. Clin. d. osp. Incur., Napoli, 1883, VIII, 136-143. Jacquet, Anevrysme du coeur, foyer de ramollissement em- bolique de la protuberance. Prog. Med., Paris, 1884, XII, 172. KiDD, P., Cardiac aneurysm. Brit. Med. Jour., London, 1884, II, 909. Legg, J. W., Some account of cardiac aneurysms. London, 1884. Newcomb, J. E., Med. Rec., New York, 1884, XXVI, 263. KiDD, P., Cardiac aneurysm. Brit. Med. Journal, London, 1884, II, 909. Richet, Anevrysme du coeur et abces thoracique, Semaine Med., Paris, 1884, IV, 517. Handford^ H., Lancet, London, 1885, I, 198. Brinkman, a.. Valvular aneurysm. New York Med. Jour., 1885, XIII, 455- Butler, G. R., Aortic stenosis; aneurysm of the aortic valves; mitral stenosis and regurg. New York, 1885, XIII, 415. Anevrysme medial double des parois du coeur. Jour, de Med., Bordeaux, 1885-86, XV, 2. Leyder, E., Uber einen fall von Herzaneurysme. Deut. Med. Woche., 1885, XI, 115. Haig^ Lancet, London, 1885, II, 1045. Salvioli, Salute italia Med., Savona, 1885, XIX, 368-370. KiDD, P., Four cases of cardiac aneurysm. Tr. Path. Soc., London, 1884-85, XXXVI, 127-133. Sharkey, S. J., Tr. Path. Soc, London, 1884-85, 133-135. Taylor, F., British Med. Journal, 1886, I, 447. PocHMANN^ E., Aneurysma cordis ventric. sin circumscriptum verum plotzlicher tod durch berstung und bluterguss in das perikardium. Wien. Med. Prcsse, 1886, XXVII, 1403. Rendu, H., Note sur un cas d'anevrysme partiel du coeur avec des remarques sur la pathogenic et la symptomatologie de cette lesion. Bull, et Mem. Sac. d. Hop., Paris, 1887, IV, 455-467. l84 THE SURGERY OF THE HEART Chavanis, Observation d'anevrysme du sinus de Valsalva ouvert dans I'artere pulmonaire. Loure Med., St. Eti- enne, 1888, VII, 1-5. Maguire, R., Tr. Path. Soc, London (1886-87), 1887, XXXVIII, 100-102. Money, A., Aneurysm of the heart, cerebral tumor, idiocy. Ibid, 97-99. MooRE, N., Aneurysm of sinus of Valsalva. Ibid, 100. YoNGE, G. H., Med. Press and Circ, London, 1888, XLV, 6.^8. Marchisio^ C, Esteso aneurisma parziale cronico del cuore per sclerosi della arterie coronaire. Rev. Clin., Milano, 1888, XXVII, 594-602. Fischer, G., Uber einen fall von aneurysma sinus Valsalva. Erlangen, 1889. Mader, J., Bertsung eines Herzaneurysma des in folga athero- matose einer Kranzarterie enstand primare schumpfiniern tod. Ber. k k Krankenanst. Rudolph-Siftung in Wien (1887), 1888, 323. Pert, Lancet, London, 1889, I, 791. NoRTHRUP W. P., Proc. New York Path. Soc. (1888), 1889, 43- Klein, G., Berlin, 1889, CXVIII, 57-69; i pi. Fischer, G., Uber einen fall von aneurysma sinus Valsalva. Erlangen, 1889. Williams, C. B., Weekly Med. Rev., St. Louis, 1890, XXI, 221-225. BoissoN G., Anevrysme du cceur, ramollissement cerebral arterite syphilitique probable de I'encephale et des coro- naires. Bull. Soc. Anat., Paris, 1889, LXIV, 534-538. De Grandmaison, Anevrysme du cceur. Ibid, 626. Lop, Anevrysme de la pointe du coeur. Marseille Med., 1890, XXVII, 566. Von Krayurcki, C., Das Septum membraneum ventriculorum cordis sein verhaltniss sum sinus Valsalva dexter aortae und die aneurysmatischen veranderungen beider. Beit. z. Path. Anat. und Allg. Path. Jena, 465-484. CARDIAC ANEURYSM 185 Marckwald, E., Zur Kenntniss des chronischen Herzaneur- ysms. Halle, 1891. BossARD, Dilatation anevrysmale du ventricule gauche et per- foration de I'estomac consecutive a une lesion cardiaque ; mort par peritonite suraigue. Med. Poitiers, 1891, V, 265-271. Mackenzie and Williams, A case of aneurysm of the heart with symptoms of angina pectoris during life. Med. Chron., Manchester, 1891-92, XV, 302-305. Mackenzie, H. W. S., Aneurysm of the heart, contracted granular kidneys. St. Thomas Hospt. reports, London, 1890-91, XX, 337. ViDAL, Observation d'anevrysme intra-cardiaque ; communica- tion du ventricule gauche avec I'oreillette droite. Loire Med., St. Etienne, 1892, XI, 121, 126. Omerod, J. A., Aneurysm of Heart. Tr. Path. Soc, London, 1890-91, XLH, 60. Lop, p. a., Contribution a I'etude des anevrysmes du cceur. Rev. de Med., Paris, 1892, XH, 558-566. Cuffer, Des anevrysmes du coeur. Semaine Med., Paris, 1893, xni, 43. Hebb, R. G., Tr. Path. Soc, London, 1892-93, XLIV, 45-47. KiDD, P., Tr. Path. Soc, London, 1892-93, XLIV, 47. Openchovsky, T. M., Rare case of aneurysm of sinus of Val- salva followed by disease of valves of heart. Vratch, St. Petersburg, 1894, XV, 705. Georgiades, Zur Kenntniss der Herz-aneurysmen. Munchen, 1894. Pettus, W. J., Bradycardia caused by aneurysm of one of the sinuses of Valsalva. New York Med. Jour., 1894, LX, 551- Vasiljeff, N. T., Kazuist aneurysma sinus Valsalva. Sovrem Klin., St. Petersburg, 1894, II, No. 10, 35. Von Openchowski, T., Uber einen seltenen fall von aneurys- ma sinus Valsalva mit nachfolgender functioneller stehung der herzklappen. Bed. Klin. Woch., 1895, XXXII, 140- 142. 1 86 SURGERY OF THE HEART Claude, H., Bull. Soc. Anat. dc Paris, 1895, LXX, 433. GuFFOX, v., Bull Soc. Anat. dc Paris, 1895, LXX, 620. Embley, E. H., a case of aneurysm of the heart and a probable diagnostic sign of such condition. Australas. Med. Jour., Melbourne, 1895, XVII, 361. GouGET, A., Un nouYcau cas d'anevrysme du cceur aYCC nephrite d'origine cardiaque. Ibid, i^y-i^^. Marie et Rabe, Un cas d'aneYrysme du coeur. Ibid, 157. Verbitski, M. K., a proof of a case of aneurysm of the heart. Trudi. Obsh. Russk. Vratch., St. Petersburg, 1894-95. LXI, 70-74. Da\is, a. N., a case of aneurysm of the heart, necropsy. Lancet, London, 1896, II, 381. CoxTi, P., Un caso di aneurisma del setto Yentricolare. Atti d. Assn. Med. Lomb., Milano, 1896, 291-318. Shat, T. S., a case of aneurysm of the heart. Brit. Med. Jour., London, 1897, I, 1146. ]Mader, J., Herzaneurysme mit relatiYcr insufficientia vahailae bicuspid dis. tod. Jahrb. d. Wien K. K. Krankenant, 1895, Leipsic, 1897, IV, pt. II, 250. Parisot et Spillman, Qideme pulmonaire et auevrysme du coeur. Rev. de Med. de Vest, Nancy, 1897, XXIX, 391- 39^5. Hare, H. A., A case of suspected cardiac aneurysm. Med. Rcc., New York, 1897, LXXXI, 728. Sailer, J., Heart with two ventricular aneurysms. Proc. Path. Soc, Philadelphia, 1897, I, 1-9. BuRGOSS, A., Des anevrysmes dissequants du coeur. Nort. Med. Ark., Stockholm, 1897, VIII, Heft 5, No. 26, 1-65 ; 2 pi. Gardner, W. J., Chronic aortic endocarditis associated with a small aneurysm which bulged into the infundibulum of the right ventricle. Glasgow Med. Jour., 1898, XLIX, 195, 198. Martin, E., Anevrysme de I'artere de la valvule mitrale. Lyon Med., 1898, LXXXVII, 267, 269. CARDIAC ANEURYSM 18/ TuRNEY, H. G., Tr. Path. Soc, Lond., 1896-97, XLVIII, 56. Caccloglu C, Aneurysm of the heart. Protok. Zasand Obsh. Morsk. Vrach. V. Kromstadt, 1896-97, XXXV, 83-88. Lemeignen, Siir iin cas d'anevrysme cardiaque. Ga^'. Med. de Nantes, 1897-98, XVI, 166. Sangree, E. B., Journal of the Am. Med. Assn., 1898, XXX, 1401. Bernard, H., Anevrysme du coeur. Bull. Soc. Anat., Paris, 1898, LXXXIII, 399. Torregiam, Aneurisma multiple delle crecchiette. Gior. d. r. Soc. Med. Acad. Ital, Torino, 1898, XLVII, 841. Callett et Steele, Tr. Path. Soc, Philadelphia, 1898, XVIII, 203-211. Drasche, a., Uber aneurysmes an der herzklapper. Wien. Klin. Woch., 1898, XI, 1017-1024. Burgess, J. J., Tr. Royal Acad. Med., Ireland, 1898, XVI, 324-326. Levashoff I. M., Sur I'anevrysme chronique du ventricule gauche du coeur ext. 397. Russk. Arch. Patol. Clin. Med. I Vak., St. Petersburg, 1898, VI, 261-361. Drasche, Philadelphia Med. Journal, May 20, 1899, speaks of three cases, a woman 66, inflammatory in character, a boy 19, result of endocarditis, and the third due to tighten- ing of cordse tendinas. Cruveilhier, Anat. Path., liv., XXI. Schroetter, Ziemssen's Handbuch, Bd. VI. Reynaud, Arch. Anevrysme in Nouveau Diet, de Med. Morgagni, Epist. XVII. Oppel, W. a. v., Beitrag zur frage der Fremdkorper im her- zen, Archives, f., Klinische Chirurgie, Berlin, 1901, Ixiii, 87-115, I taf. KoHLEPP, Tod, in folge verletzung einer herzvene, Mitthcil- ung d. ver. bad. Thierdrt:;e, Karlsruhe, 1901, i. 44-45. BouREAu, Maurice, Le massage du coeur mis a nu, Revue de Chirurgie, Paris, 1902, xxvi, 526-532. l88 THE SURGERY OF THE HEART Stubbe, Paul, Ein fall einer eigenartigen herzverletzung in- augural dissertation, Erlangen, 1902, September, No. 26. Wetzel, Uber verletzungen der brust speziell des herzens. Miinchcn Medicinische Wochenschrift, 1902, xlix, 1260- 1264. Wagener, Oskar, Ueber die methoden der freilegung des her- zens zur vornahme der nahtnach verletzungen inaugural dissertation, Kiel, 1902, Juni u Juli, No. yy. CHAPTER IX FOREIGN BODIES It has been shown that many kinds and sizes of foreign bodies may form within, or enter from without the heart, and yet hfe be maintained indefinitely. Foreign bodies in the hearts of bipeds are usually found in the floor of one of the two ventricles. The heart of quadrupeds is in a different posi- tion. It falls backward when man is upon his back, and forward as the dog walks about, or Hes down. Historical (1814-1903). — Wood (1814) wrote an interest- ing account of a dissection of a patient in which a foreign body was found within the heart. Sheward and Davis also report such cases. Leaming (1843) mentions a case of a needle entering the right breast, and finally lodging in the heart, causing death. Graves (1847) relates a remarkable case of suicide, and ex- traction of a needle from the substance of the heart. Neill (1849) ^Iso relates such a case, resulting in death. White (1853) reports a case of aneurysm of the left axillary artery, with ligature of subclavian artery, and lodgement of a musket- ball in the heart. In the case of Greene, a needle that had lodged in the right bronchus, and perforated the heart, produced death. Hamilton (1867) reports a gunshot wound of the heart, the ball being embedded in the wall of the right ventricle for twenty years. Death resulted from pneumonia. Balch (1867) also had a case in which the ball remained in the heart for twenty years. Ambrose (1870) recorded a case of a pin, that had become encysted in the wall of the heart. 190 THE SURGERY OF THE HEART Callender (1871) successfully removed a needle that had entered the heart, and the patient made a perfect recovery. This seems to be the first surgical operation successfully per- formed upon the heart. Ryerson reported a needle in the heart. Halley (1878) reports a case of a ball, fifty-five days in the heart, causing death while the man was working in the field. Fayrer (1879) reports an interesting case of a dissection of a case, in which a foreign body was found within the heart. Murdock (1880) mentions a case of a thorn in the heart. Balch (1882) had another case in which a ball remained in the heart for eighteen years. He recovered from effects of wound in six weeks. Ferris (1882) reports a case of a man living twenty days, with a skewer traversing his heart. Pool's (1889) case survived eleven days, with a bullet em- bedded in the apex of the heart. Polland alludes to a case in which a lad lived five weeks, with a piece of wood in the right ventricle. Agnew cites another case, in which the patient survived three weeks with a watchmaker's file in his heart, the tool having passed through the left ventricle and right auricle. Haller reported (Agnew) the case of a needle being found in the heart of a bullock. Iverhardt reported twenty-two cases of needle in the heart (nineteen of which were discovered post-mortem), w'hich were not suspected. BIBLIOGRAPHY Wood, W., Edinb. Med. and Sjirg. Jour., 1814, X, 50-54. Sheward, G., London Med. Gan., 1834, XIV, 541-543. Davis, T., Tr. Prov. Med. and Surg. Assn, London, 1834, II, 357-360; I pi. Also London Med. Gas., 1834, XIV, 345. Leaming, B. F.. Med. Exam., Philadelphia, 1843, VI, 112. Graves, J. G., Analyst, New York, 1847, II, 50. Neill, J., Med. Exam., Philadelphia, 1849, "-S-i V, 93-95. White, W., Indian Am. Med. 5(^f.. Calcutta, 1853, 1, 289-295. Plate XXIII. X 97. Carcinoma, (Epithelial). *>*.; *r" 4', X 2G0. Carcinoma, (Deep-Seated). (Chapter on Malignant Tumors.) FOREIGN BODIES 191 Ingram^ S. L., Remarkable Phenomena of the Heart, Virginia Med. Jour., Richmond, 1859, XII, 378. Balch^ G. B., Am. Journal Med. Sc, Philadelphia, 1861, n,s., XLII, 2893. Also Med. Repor., New York, 1867-68, n.s., I, 91. Green, T. H., Tr. Path. Soc, London, 1866, XVII, 89. Hamilton, New York Medical Journal, 1867, IV, 379-382. Ambrose, D. R., Med. Rec., New York, 1870, V, 83. Callender, Proc. Roy. Med. and Surg Soc, London, 1871, 1875, VH, p. 116. Ryerson, T., Tr. Med. Soc. New Jersey, Newark, 1877, 259. Fayrer, J., Lancet, London, 1879, I, 658. H ALLEY, Of Conn., 1878. Murdoch, E. P., Peoria Med. Monthly, 1881, I, 135. Balch, Gross, Surgery, Vol. II, 1882, 382. Davis, Gross, Surgery, 1882, Vol. II, p. 382. Ferris, Gross, Surgery, Vol. II, 1882, p. 382. Pool, Agnew's Surgery, Vol. I, 1889, 424. Sengenesse, B., Considerations sur un cas de corps etranger du coeur chez un enfant de trois ans. A?in. de la Policlin. de Bordeaux, 1893-94, III, 249-260. Haller, Bibliotheca Chirurgica, Vol. II, p. 378. IvERHARDT, Aguew's Surgcry, Vol. I, p. 425. Polland, Reported by David and Stewart Syst. of Surg., Vol. II, p. 606. CHAPTER X CARDIOLITHS Cardioliths and concretions are quite common, and orig- inate from the blood, polypoid growths, clots, or microorgan- isms. If a nucleus be present, it may be any foreign body that may have entered the substance of the heart, or any of its chambers. Cardioliths may enter any chamber after having formed in any portion of the cardiac substance, and at once become foreign bodies, and might be so classed. Historical (1700-1903). — Goodwin (1700) recorded a case of polyform concretions of the heart. At the same time he reported several cases of stones in the heart. Vernon ( 1826) gives quite a lengthy report of a case of obstruction to the passage of blood through the right auriclo-ventricular opening of the heart, from a fibrous concretion, which was en- tangled under the tendinous cords of the tricuspid valve. Bricheteau (1834) reported a similar concretion of a fibrous character. Hache (1832) found such concretions in a tuber- culous subject. Aubrey (1836) observed fibrous concretions, causing obstruction to the circulation. He thought them to be due to microorganisms. Hardy (1838) attributed their formation, in his case, to a vegetable ferment. Hughes (1838) reported his observations on fibrous concretions, in eleven cases. Bouilland (1839) believed that the concretions found in his patient were from the blood alone. In the case of Sprague (1848) there were fibrinous concretions in the heart, extending into the pulmonary artery and aorta with extensive hepatiza- 192 CARDIOLITHS I93 tion of both lungs. Garstang ( 1852) mentions a case of death, clue to a fibrinous concretion of the heart. Barbieri (1852) of Milan reports a case, in which a fibrous polyp extended from the ventricle through the aortic orifice. Richardson (1855), it seems, was among the first to write upon the diagnosis of fibrous concretions in the heart. Blondet (1857) wrote voluminously upon the subject, but could offer nothing definite in determining their cause or presence. Haus- ley (1858) reported a death from a fibrous concretion in the right heart. Its presence in the right, is less frequent than in the left heart. It remained for Ogle (1862) to report the largest cardiolith. It was globular, and one inch in diameter, " lying loose " within the left auricle of the heart. It was fibrous in character. There was induration of the suprarenal capsules. During the year 1864 Faure made an experimental research concerning fibrinous clots and the products of inflammation. In 1866 he reported upon a case of extensive fibrinous concretions in the heart. Monard (1867) wrote an interesting paper on the general considerations of concretions found in the blood. Faure and Monard deserve much credit, as they were among the first to explain the character of these bodies. Barbancy (1869) appears to be the first to report fibrous concretions as being due to pneumonia. Fayrer (1870) states that death was due to fibrinous concretions in the right side of the heart, in a subject suffering from urethral fever. It is pos- sible that in each of these cases the presence of concretions was coincidental. Fayrer (1873) reports another case, in which a fibrous concretion was found in the right heart. Lawson (1873) reports two such cases. Baker (1874) found them in the heart and large vessels. Hattute (1875) ^"^ Rendue (1875) ^^ch report concretions found in the heart of tuber- culous subjects. Chaffey (1887) mentions a case, in which fibrous deposits were found in the heart of a patient having diphtheria. May- 194 THE SURGERY OF THE HEART cock ( 1888) States that he found pecuhar deposits in the heart and aorta, while Delepine ( 1889) describes a cardiohth. BIBLIOGRAPHY Goodwin, J. W., Phil. Tr., London, 1700, III, 70-76; i pi. Cases, Phil. Tr., London, 1700, III, 158. Vernon, H., Edinburgh Med. and Surg. Jour., 1826, XXVI, 76-79. Brichetau, Jour. Jlebd. dc Prog,, de Sc. et I'lnst. Med., Paris, 1834, IV, 39-44. Aubrey, Rec. de mem. de Med. Mil., Paris, 1836, XL, 270- 281. Hardy, Paris, 1838. Hughes, H. M., Guy's Hospital Rep., London, 1839, IV, 146- 190; 2 pi. Also Med. and Surg. Monographs, 80, Phila., 1840, 105, 136. BouiLLAND, Experience, Paris, 1839, III, 273, 337. JoY, W. B., Polypous concretions of the heart. System Pract., M. Tweedie, Philadelphia, 1841, III, 556-560. Epidemic de concretions fibrineuses du ccEur. Rec. de Med. Mil., Paris, 1842, III, 63-71. Sprague, G., Illinois and Indiana Med. and Surg. Jour., Chi- cago, 1848, II, 402-6. Choisy, Observation de polype fibreux du coeur. Soc. Med. de Gannat, Rap. gen, etc., Cusset, 1848-49, 44-51- Garstang, W., Lancet, London, 1852, II, 191. Also Med. Times, London, 1852, n.s., V, 259. Also Prov. Med. and Surg. Jour., London, 1852, 658. Barbieri, Gas. Med. Ital. Lonih., Milano, 1852-53, s. Ill, 397- 402. Barth, Un caillot adherent dans le ventricule gauche du coeur formant une masse ferme et resistante. Bull. Soc. Anat. de Paris, 1853, XXVIII, 86-88. Richardson, B. W., Med. Circ, London, 1855, VI. 193. CARDIOLITHS 1 95 Blondet, Union Med., Paris, 1857, XI, 463, 471, 485, 497, 504, 516, 529. HousLEY, C, Med. Times and Gac, London, 1858, XVI, 425. Ogle, J. W., Tr. Path. Soc, London, 1862, XIV, 127. Faure, Produits d'inflammation du coeur. Arch Gen. dc Med., Paris, 1864, I, 129-150. Ogle, Tr. Path. Soc, London, 1866, XVII, 71. MoNARD, MontpeHer, 1867. Todd, J. S., Fibrinous Concretions in the Heart. Am. Jour. Med. Sc., Philadelphia, 1869, n.s., LVII, 109. Barbancey, Bidl. Soc. Anat. de Paris, 1869, XLIV, 1 91-193. Fayrer, J., Jordian A. M. St. Calcutta, 1870, No. XXVII, 30- 35- D'EspiNE, Infarctus multiples dus a des caillots emprisonnes dans les anfractuosites caverneuses du ventricule gauche. Bull. So'c. Anat. de Paris, 1871, XLVI, 59-61. Rendu, Bull. Soc. Anat. de Paris, 1872, XLVII, 405. Lawson, R., Med. Times and Ga^., London, 1873, I, 138. Fayerer, J., Med. Times and Gan., London, 1873, i, 58-60. Baker, B., Canada Med. Rec, Montreal, 1874-75, III, 429- 434- Hattute, Rec. Mem. de Med. Mil, Paris, 1875, XXXI, 250- 262. Burnett, W. R., Heart with Calcareous Plates. Tr. Path. Soc, London, 1881, XXXII, 53. Ribrail, Polypes Fibrineux du Coeur. Bull. Soc. Anat. de Paris, 1883, LVIII, 191-193. Roy, G. C, Fibrinous coagula in the heart. Indian Med. Gaa., Calcutta, 1883, XVIII, 117-119. Williams, A. D., Cardiac Thrombosis. Asylum Med. J., Berbice, 1884, No. 362. Cenas, Concretion sanguine remplissant Toreillette gauche. Loire Med., St. Etienne, 1886, V. 169-177. Schmidt, M., Ein fall von Concretio Cordis. Deut. Med. IVoch., 1886, XII, 936. Chaffey, W. C, Brit. Med. Journal, London, 1887, II- i-i- 196 THE SURGERY OF THE HEART MoGLiA, C, Un caso di thrombosi purulenta del cuore de metas- tari. Morgagni, Napoli, 1887, XXIX, 623-630. Maycock, B. J., Med. Rcc, New York, 1888, XXXIV, 703. Delepine, S., Tr. Path. Soc, London, 1889-90, XLI, 43-53; I pi. Edwards, W. A., Some Unusual Heart Clots with Remarks upon White Thrombi. Pacific Med. Jour., San Fran- cisco, 1889, XXXII, 657-660. Banks, C. E., The Frequency of Heart Clots. Rep. Superv. Surg.-Gen. Marine Hospital, Washington, 1 890-1 891, XIX, loi. Von Ziemssen, Zur Pathologic und Diagnose der Gestelten und Kugelthromben des Herzens. Verhandhing d. cong. f. inner Med., Wiesbaden, 1890, IX, 281-285. Gem MEL, J. F., A Case of Cardiac Thrombosis with Multiple Embolism of the Lungs; necropsy. Lancet, 1891, I, 1041. Berge, a.. Polype Fibrineux de I'Oreillette Gauche. Bull., Soc. Anat., Paris, 1892, LXVII, 323-325. Stance, P., Uber einen fall von Kugelthrombus im vorhof des linken Herzens. Gottingen, Berlin, 1893. Krumbholz, Zur Casuistik des gestelten Herzpolypen und der Kugelthromben. Arh. a. d. Med. Klin, su Leipsic, 1893, 328-331. Krumm F., Zur Casuistik destelter Herzpolypen. Deut. Arch. f. Klin. Med., Leipsic, 1894-95, LIV, 189-200. March and, F., Zur der Embolic und Thrombose der Gehirn- arterien zu gleich ein beitrag zur Casuistik der primar- ten Herztumoren under der gekreutzen Embolic. Berlin Klin. Woch., 1894, XXXI, i, 36, 62. MiCHELi, Thrombosi delle orechiette del cuore diagnostica in vita. Settimana Med. de Sperimentale, Firenze, 1896, I, 87-89. Drozda, J., Concretio cordis cum pericardio insufficientia valv. mitralis aortse et triscuspidalis. Tod. Jahrh. d. IVien. k. k. Krankenanstalt, 1895, Wien and Leipsic, 1897, IV, pt. 2, 238. CARDIOLITHS 197 Allais, a., Contribution a I'Etude de la Thrombose Cardiaque, Paris, 1898. Varnali and Jonescu^ Uber einen fall von Concretio Cordis mit Herzdilatation. Med. Chir. Ccntrhl., Wien, 1898, XXXIII, 572. MoDicA^ O., Reperto di coaguli fibrinosi nel cuore in morte rapida. Terap. Clin., 1898, VII, 121-126. Brooks, A., Clot of the Aortic Valve causing Misleading Phys- ical Signs. Proc. N. Y. Path. Soc. (1897-98), 1899, 244. DiEMER, F., Uber Kalkablagerum gen. an den serosen Hauten des Herzens. Ztsch. f. heilk., Berlin, 1899, XX, 257-296. Hay, J., Cardiac Thrombi. Liverpool Med. Chir. Jour., 1900, XX, 327-332. LoHLEiN, M., Uber Kugelthromben des Herzens. Giessen, 1900. CHAPTER XI CALCIFICATION Calcification is a deposit of calcium carbonate or phos- phate often found associated with some of the salts of mag- nesium. It may be deposited in the endothelium on the inter- muscular fibres. It is usually preceded by fibrosis and due to weak circulation, and chronic irritation. Gibson says " the nature of the process which leads to the deposition of lime salts is absolutely unknown," and that no more definite hypothesis can be assumed at present than that soluble become altered into insoluble salts. Historical (1822-1903). — Rost (1822), Rainy (1827), Richardson (1830), Pierson (1834), Douglas (1838), Wood (1850), and Pierce (1852), have found ossific formations in the heart, the last named having also observed them in a hog. Wilks (1856), Cleveland (i860). Gay (1872), and Egan (1876), also mention cases. In the case of Eskridge (1884), the ossification was at the aortic orifice. Emmet (1855) reports a case of calcareous deposits on the surface of the heart, with reference to the manner in which the blood is propelled from that organ. Ogle (1859) had a case in which such deposits surrounded the heart substance. Coats (1871) had a similar case, and reported two cases of calcare- ous infiltration of the muscular fibres of the heart. Harduch (1880) observed a similar one, and O'Toole (1880) found in- filtration in the apex of the heart, at the same time writing extensively on the aetiology and pathology of such infiltration. Rechardiere (1883) recognized these deposits about the CALCIFICATION 199 aortic valves and ventricular walls. Robin (1885), Guinou (1885), Drummond (1888), Wolff (1891), Bromwell (1895), and Bromwell and Gulland (1896), and Faitout (1896), all report interesting cases of this character. BIBLIOGRAPHY RosT, T., Med. and Phys. Jour., London, 1822, XLVIII, 474. Rainy, A., London Med. and Phys. Jour., 1827, n. s., Ill, 480-482. Richardson, J., Glasgow Med. Jour., 1830, III, 397. PiERSON, A. L., Med. Mag., Boston, 1834, III, 29. Chalignez, J., Extrait d'une memoire des cristaux a quatre cris- tallisations diffe rentes deposees dans la substance du coeur; nouvelle maladie de cet organe. 4to, Versailles, 1837. Douglas, G. M., Boston Med. and Surg. Jour., 1838, XVIII, 156. Wood, J., Tr. Path. Soc, London, 1850, III, 66. Pierce, J. L., Am. Med. Jour. Sc, Philadelphia, 1852, n. s., XXIV, 279. Emmet, T. A., New York Med. Times, 1855, IV, 154-159. WiLKS, Tr. Path. Soc. London, 1856-57, VIII, 100. Ogle, J., Tr. Path. Soc. London, 1859-60, XI, 71-76. Cleveland, W. F., Lancet, London, i860, 1, 92. Coats, J., Glasgow Med. Jour., 1871-72, IV, 433-451. Gay, N., Tr. O. M. Soc, Cincinnati, 1872, 14; also Cincinnati Med. News, 1872, 1, 328; also Med. and Surg. Reporter, Phila- delphia, 1872, XXVII, 3. Egan, R. W., Brit. Med. Jour., London, 1876, II, 749. Harduch, Med. Rec, New York, 1880, XVIII, 552. O'Toole, M. C, Tr. Med. Soc, California, 1880, X, 118-121. Bruon, Encephaloide du coeur, generalisation dans les visceres. Bull, de la Soc. Anat., Paris, 1883, LVIII, 407. Richardiere, Atherome generalise, retrecissement aortique avec atherome des valvules aortiques, calcification de I'endocarde du ventricule gauche. Bull, de la Soc. Anat., Paris, 1883, LVIII, 499. Calcified pericardium; double mitral disease. Bost. Med. and Surg. Jour., 1884, CX, 37. 200 THE SURGERY OF THE HEART EsKRiDGE, J. T., Tr. Path. Soc, Philadelphia, 1881-83, 1884, XI, 89. Fibrous and calcareous degeneration with stenosis of mitral and aortic valves; ulceration of the angles of the mitral slit. Tr. Path. Soc. London, 1884-85, XXXVI, 144. Robin, A., Bull, et mem. Soc. Med. d. hop, Paris, 1885, II, 99-101. Kraus, F., Zur casuistik der myomalacia cordis. Prag. Med. Woch., 1885, X, 425-427. GuiNOX, L., Bull. Soc. Anal., Paris, 1885, LX, 514. Weber, C. A., Contribution a I'etude anatomo-pathologique de I'arteriose du cceur (sclerose du myocarde). Paris, 1887. Variot, G., Cuirasse calcaire enveloppant le ventricule droit du coeur; mort subite dans le cours d'un epanchement pleural. Rev. de Med., Paris, 1888, VHI, 746-751. Drummoxd, D., Northumh. and Durham Med. Soc, Newcastle- upon-Tyne, 1888-89, 169; I pi. Notes of a case of calcareous disease of the heart and pericardium. Am. Jour. Med. Sc, Philadelphia, 1890, XCIX, 153-158. Borchers, C. W., Uber compHkation von amyloid-entartung mit endokarditis. Kiel, 1889. Rothschild, A., Uber die entstehung der herzschwielen. Freiburg, 1890. ViTi, A., La sclerosi del miocardium. Riv. Clin., Milano, 1890, XXIX, 219-265. Patton, J. M., Cardiac degeneration. Clin. Rev., Chicago, 1897- 98, VIII, 99-102. Von Reckhnghausen uber die storungen des myocardium. Verhandlung, Interna. Cong. Med., 1890, BerHn, 1891, II, 3 Abth. 67-74. Von Zenker Storungen des myocardium Verhandlung z. x., Intemat. Med. Cong., 1890. Berhn, 1891, II, 3 Abth, 74-81. Wolff, L., Tr. Path. Soc. Philadelphia, 1891, XVI, 136. OsLER, W., Anaemic necrosis of the heart muscle. Tr. Path. Soc, Philadelphia, 1887-89, 1891, XIV, 125. Meigs, A. V., Cystic degeneration of the muscular fibres of the heart, a form of disease hitherto undescribed. Tr. Coll. Phys., Philadelphia, 1892, XIV, 28-35; i pi. Kast and Rumpek, Myodegeneratio cordis et thrombosi arteriae Plate XXIV X 47. Cysticercus. X 75. Eggs of Cysticercus. (Chapter on Animal Parasites.) CALCIFICATION 20I coronariae; ancurysma cordis continens in eis. Path. Anat. Tafeln. Hamb. Staatskrankenhaus, Wandsbek. Hamb. 1893, 7 hft. pi. C 4, with text. RoNDE, J., Zur aetiologie der herzschwielenbildung. Wurzburg, 1893. LipPERT, H., Uber amyloidentartung nach recurrirender endo- carditis. Tubingen, 1895. Bramwell, B., Tr. Med. Chir. Soc, Edinburgh, 1895-96, XV, 97, lOI. Dehio, K., Die diffuse vermehrung des bindegewebs im herz- fleische (myofibrose). Verhandlung d. cong. innere Med., Wiesbaden, 1895, XII, 487, 495. GuRViCH, M. I., Myofibrosis cordis patholoanatomischeskoye izsUcdovanie (patho-anatomical research). Yuryew, 1896. Bramwell and Gulland, Edinburgh Hosp. Report, Edinburgh and London, 1896, IV., 1575, 199; 2 pi. Faitout, Bull. Soc. Anat., Paris, 1896, LXXI, 279. DuMiTRiEFF, A. N., Myocarditis interstitialis fibrosa Voyenno. Med. Jour., St. Petersburg, 1897; CLXXXIX, Med.-Spec. pts. 1122-1135. Bugge, J., Om degeneration af hyertemuskulaturen og dens be- tydning Norsk. Mag. f. Leagevidensk, Kristiana, 1897; 4 R., XII, 1027, 1041. Lemoine, La myocardite parenchymateuse. Rev. Prat. d. Trav. de Med., Paris, 1897; LIV, 161. Myofibrosis cordis. Compt. Rend. Cong. Internat. de Med., 1897; Moscow, 1899, III, Sect. 5, 271-275. Hervouet, Sur un cas de cirrhose cardiaque. Gaz. Med. de Nantes, 1898, 1899, XVII, 5052. Jacobsthal, H., Verhaltung von herzmuskelfasen bei einem kinde. Arch. f. Path. Anat., etc., Berlin, 1900; Clin., 361-4. Gibson, C. A., Acute heart softening. Edinburgh Hospital, 1900, VI, 40-8. VON Pessel, F., Calcification of the heart. Munchen.Med. Woch., June 10, 1902. CHAPTER XII ABSCESS Abscess of the heart is usually py?emic, and associated with disease of the bones and joints, cancer, phlebitis, myocarditis, and chronic ulcers, especially about the genito-urinary tract. Cardiac abscesses occur as multiple yellow spots under the pericardium or endocardium, varying in size from a millet-seed to a bantam's egg, and situated, as a rule, at the base of the left ventricle in the papillary muscles. They may remain semi- solid, or they may contain fluid and rupture into the peri- cardial space, or into one or all of the chambers of the heart, and so finally enter the general circulation. Death may not ensue from either kind of rupture, the result depending upon the character of the fluid, its amount and the condition of the pa- tient at time of rupture. Historical (1833-1903). — One of the earlier reports of ab- scess of the human heart is by Broussais ( 1832). Such a con- dition was found in the heart of a horse by Parry ( 1835). Hewitt (1846), mentions a remarkable case of abscess of the heart, with pain in the leg as the only symptom during life. Chance (1846) gives an account of abscess of the heart found post mortem, as does Stallard. Mayne (1847) speaks of a purulent cyst of the heart; McCormick (1851) of an abscess of the right ventricle; Rankin (1852) of an anomalous case of scrofulous abscess; Banks (1852) of purulent cardiac cysts. Holmes (1857) mentions a secondary cardiac abscess from pyaemia in the heart-wall, and Maxon ( 1869) reports a case of abscess of the heart bursting into the left ventricle. ABSCESS 203 Wooster (1872) reports a case of abscess of the heart-wall with disease of the valves, incompetence of left sigmoid valves, physiological tricuspid incompetence, and anasarca, with pain- less death by gradual asphyxia from super-carbonized blood. In 1872, Langluirst mentions a scrofulous abscess in the wall of the left ventricle, as does Crisp during the same year. The case of Crisp was due to pyaemia. Maxon ( 1872) reports a case of abscess of the heart and kidneys with suppurative periostitis, and Dennis (1895) records a case of abscess in the wall of the left auriculo-ventricular valves, about the size of a walnut, which had opened into the ventricle. The duration could not be determined from the symptoms. Following is a case reported to me direct. " Dear Doctor : With regard to my own case of cardiac abscess, I briefly reported it in a Chicago medical journal I think for 1877. As I have not access to its files I cannot give you the references. My recollection of the case is to this effect. A hospital patient was suffering from dyspnoea, and proved to have a very much dilated pericardium, which at the time was considered to be full of serum. One night in his extremity of distress, I decided to try to relieve him by use of the aspirator. You will recall that this was in the early day of the aspirator and this was almost my first experience with it. I pushed a needle in and withdrew, not serum, but to my surprise, three or four ounces of pus. The man was temporarily relieved but died a few hours later. Autopsy showed a pericardium with considerable serum and an abscess cavity of the heart-wall nearly emptied, into which my needle point must have pene- trated. " Whatever else may be said about the case, I think I may certainly claim accidental priority in tapping an abscess in this locality. " Very truly yours, "RoswELL Park. "Buffalo, N. Y., October 4, 1902." 204 THE SURGERY OF THE HEART BIBLIOGRAPHY Broussais, C, Ann. de la Med. Physiol., Paris, 1832. Krauss, Eiterabscess in der herzsubstanz. Med. Correspond- ence Blatt., d. Wiirtemburg. Aerztl. von Stuttgart, 1833, II, 189-191. Parry, R. B., Indian Med. Jour. Sc, Calcutta, 1835, II, 299. GoiTRAC, Cordite partielle, abces du sommet du ventricule gauche, trajet fistuleux ouvrant a la surface du cceur. Bull. Acad. de Med., Paris, 1842, VIII, 856-859. Hewitt, T., Lancet, London, 1846, I, 684. Chance, E. J., Lancet, London, 1846, I, 548-550. Stallard, J. H., Prov. Med. and Surg. Ass'n., London, 1847, XV, 105-116 ; I. pi. Mayne, R. St. J., Proc. Path. Soc, Dublin, 1847-52, 274. Beauvais, Pericarde adherent, abces du coeur. Ibid, 1847, XXII, 172. Lange, E. W., Abcess des herzens in his bcob. am Krankenbette et Konigsburg, 1850, 189-19 1. McCoRMiCK, New Orleans Med. atid Surg. Jour., 1851-52, VIII, 890. Ranking, R., Prov. Med. and Surg. Jour., London, 1852, 659. Banks, J. T., Proc. Path. Soc, Dublin, 1852-58, 27. Barth, Diathese purulente; un nombre de foyers purulents dans les muscles; un petit abces dans les parois du coeur. Bull. Soc. Anat., Paris, 1855, XXX, 6. Holmes, T., Tr. Path Soc, London, 1857-58, IX, 164. KiEMANN, Periostitis femoris, oedema et hypertrophia cerebri ; peri- carditis, abscessus cordi, pneumonia lobularis. Der. d. k. k. Krankenanstalt, Rudolph Siftung, Wien (1866), 1867, 223. Roth, M., Ein fall von herzabscess. Arch. Path. Anat., etc., Ber- lin, 1867, XXXVIII, 572-574. Maxon, Tr. Path. Soc, London, 1869, XX, 113, Smith, P. H., Suppuration of the heart. Tr. Path. Soc, London, 1870, XXI, 94. ABSCESS 205 WoosTER, D., Pacific Med. and Surg. Jour., 1872, VI, 324-8. LONGHURST, A. E. T., Army Medical Dept., London, 1872, XII, 514. Abscess of the heart and kidneys with suppurative peri- tonitis, a distinct kind of pyaemia. Med. Times and Gaz., London, 1872, II, 351, Crisp, E., Tr. Path. Soc, London, 1872, XXIII, 8794. Maxon, Med. Times and Gaz., London, 1872, II, 351. Crisp, E., Tr. Path. Soc, London, 1872, XXIII, 8493. Montard-Martin, Abces metastatique du cceur. Bull. Soc, Anal., Paris, 1875, I, 775. BuRCKHARDT, G., Fall con idiopatischen herzabscess. Corres- pondenz Blatt. Schw. yErlze, Basil, 1876, VI, 475-480. Stevenel, C, Contribution a I'etude de la myocardite interstitielle et de I'abces du coeur. Paris, 1882. RiCHET, Aneurysme du coeur et abces thoracique. Semaine Med., Paris, 1884, 2 s., IX, IV, 517. Allard, J., Des kystes puriformes du cceur. Paris, 1890. FoRMAD, H. F., Abcess of the heart. Tr. Path. Soc, Philadelphia, 1891-93, XVI. Dennis, Sys. Surg., 1895, Vol. I, p. 405. Crouzon AND May, Abces metastatique du coeur. Bull. Soc. Anat., Paris, 1896, LXXI, 860. Favir, M., Abscessus cordis. Feldschr, St. Petersburg, 1899, IX, 349-351 CHAPTER XIII SYPHILIS It has been conclusively demonstrated that syphilis causes a large proportion of the more serious cardiac affections, espe- cially after middle life, an age when chronic valvular disease is not due to endocarditis. Syphilis is often associated with other factors in the production of heart troubles, especially strain and alcoholism. (Bruce, British Medical Journal, ]\Iarch 23, 1901.) Description (1862-1903). — Syphilis is an exciting and pre- disposing cause of muscular and valvular lesions of the heart. Cohn believes that the condition of the heart muscle is the most important point to consider therapeutically, and for the purpose of prognosis, in all cardiac diseases, except mitral ste- nosis (Philadelphia Medical Journal, Vol. 7, No. 3, p. 106, 1 901) ; " many of the changes in the heart-muscle are depend- ent upon pathologic changes in the arterial system." Many cases of myocarditis, especially acute cases, are due to syphilis. The pain in cardiac diseases is due to the fact that the various visceral nerves are connected with the nerves of the corresponding parts of the body. The greater fre- quency of myocarditis in negroes is on account of syphilitic in- fection. (Bishop, Philadelphia Medical Journal, Vol. 7, No. 3, 1901, p. 106.) These conditions do not generally begin until ten to twenty years after the initial lesion, and are more common in men than in women ; they are slow as a rule in manifesting themselves and the prognosis is grave. 206 SYPHILITIC GUMMATA 207 Fibrosis and gummatous deposits constitute the two forms of syphilitic affection of the heart. It is, however, only the gummatous form that will be considered. Ricord, Virchow, and Lancereaux w^ere among the first to observe gummata in the heart. They showed that these le- sions may be diffuse or circumscribed, dry and yellow, or of a caseous character. Such infiltrations may occur in any por- tion of the cardiac tissue and undergo fibrous transformation. These masses do not soften and discharge except in the super- ficial heart muscles. Haldane in 1868 reports a case in which he found a syphi- litic deposit in the substance of the heart. Pick during the same year recorded one of fibroid degeneration of the heart with aneurysm in the right ventricle and the interventricular sseptum in a syphilitic patient. There are several cases of syphi- litic heart affections reported during the ten years following that of Haldene. Pepper mentions a case of extensive syphi- litic disease of the pericardium, pleura, and peritonaeum, in which a paracentesis of the chest and abdomen w^as made. Gummatous infiltration of the muscular wall of the heart lead- ing to aneurysmal pouching and rupture has been recorded by Pitt, and also by Pelletier. BIBLIOGRAPHY Haldane, D. R., Edinburgh Med. Jour., 1862, VIII, 435-445. Pick, T. P., Tr. Path. Soc, London, XIX, 1869, 156-158. Fowler, R,, Fibroid (probably syphilitic) degeneration of the heart. Tr. Path. Soc, London, 1868, XIX, 1 08-1 11. Morgan, J., Cases of syphiHtic deposit in the heart. Med. Press and Cir., London, 1868, VI, 425; i pi. Lego, J. W., Case of syphilitic gumma of the heart. St. Barth. Hospt. Report, London, 1872, VIII, 183-185. Janeway, E. G., Syphilis as a cause of heart disease. Med. Fee, New York, 1872, VII, 304. 2o8 THE SURGERY OF THE HEART McNalty, G. W., Syphilitic gummata of the heart. Med. Times and Gaz., London, 1873, !> ^24. Smith, R. S., Syphiloma of the heart. Tr. Brit. Med. and Surg. Soc, 1874-78. Caylet, Syphihtic disease of the heart. Tr. Path. Soc, London, 1875, XXVI, 32. Pepper, W., Phil. Med. Times, 1876, VII, 137. Gould, A. P., Case of syphihtic heart. Tr. Path. Soc., London, 1876, XXVII, 69. Shattock, L. G., Mucous tumor of the heart (syphilitic gumma) cordis, specimen. Tr. Path. Soc., London, 1881, XXXII, 77. Henderson, C. G., Syphilitic gumma of the heart. Tr. Path. Soc, London, 1882-83, XXXIV, 53-55. Leyden, Syphilitischer herzaffection. Deut. Med. Woch., 1883, IX, 419. Profeta, La, Sifilide acquisite del cuore e dello sere membrane serose. Fugressia, Palermo, 1885, O, 160-165. Paste AUR, W., A Case of diffuse syphiloma of the heart. Tr. Path. Soc. London, 1887, XXXVIII, 105-107. Green, A. W., Ruptured aneurysm of the heart (Syphihs). Tr. Path. Soc, London, 1887, XXXVIII, 102. Mathieu, a., Syphihs. Gaz. d.Hop., Paris, 1888, LVI, 163-165. Bargum, O., Ein fall von syphilis der myocardium. Altona, 1888. VoN Der Melbe, A., Die muskel-gummata und ein neucs gumma des myocardium. Wurzburg, 1888. Mayer, G., Formas curavers des molestias chronicas der thoracac indusive a syphihs cardiaca. Rio de Janeiro, 1888. Aqua, Sifhlopatia cardiaca. Rev. Esp. de Ojtal. Dermatol, sij., etc. Madrid, 1889, XIII, 3-17. Maunac, M. N., Syphilis of the heart, including the valves. Med. Obozr., Mosk., 1889, XXXI, 765-768. Long, T., Die syphilis des herzens. Wien, 1889. Star VINE, A., Cuore sifilitico miocardite cronica interstiziale gom- mosa in requito e infezione sifilitica. Prog. Med., Napoli, 1889, III, 551-761. SYPHILITIC GUMMATA 209 Smyth, J., Syphiloma of the heart. Tr. South Indian Branch Brit. Med. Ass'n, Madras, 1889, III, 81. Sacharjin, G. a.. Die lues des herzens von der klinischen seite betrachted. Deut. Arch. Klin. Med., Leipsic, 1889-90, XL VI, 388-397- Pelletier, L., Arch, de Med. et Pharm. Mil., Paris, 1890, XV, 369-372. Pitt, G. N., Tr. Path. Soc, London, 1890-91, XLII, 61. Palma, p., Ein Fall von luetischer erkrankung der hnken coro- narterie des herzens. Prag. Med. Woch., 1892, XVII, 55-57. RoLLESTON, H. D., Multiple syphilomata in wall of the right ven- tricle of the heart. Tr. Path. Soc, London, 1892-93, XLIV, 35- Semmola, M., Lectures on cardiac syphihs. Med. Press and Circ, London, 1893, LV, 271-273. CusHMANN, H., Herz syphilis. Arb. a. d. Med. Klin, zu Leipsic, 1893, 226-236. De Renzi, E., SuUa sifiHde del core. Gazz. d. osp., Milano, 1893, XIV, 682-685. Kockel, R., Beitrag zur pathologischen anatomic der herzsyp- phiHs. Arb. a. d. Med. Klin., Leipsic, 1893, 294-302. Mraeck, F., Die syphilis des herzens bei erworbener und ererbter lues erzentrisch. Arch. }. dermatol, u. syph., Leipsic, 1893, 279-411; 4 pi. VoLMAR, H., Ueber gummata des herzens. Kiel, 1893. Dehio, K., De syphilis des herzens. St. Petersburg Woch., 1894, XI, 407-410. Yamasaki, K., Syphilitic lesions of the heart. Tjishimpo, Tokyo, 1894, No. 16, 56-62. Councilman, W. T., A case of upward syphihs of the heart, Med. and Surg. Reports, Boston City Hospital, 1894, 5 s., 85-92. Vetchtomoff, E., Stuch myocarditis syphiliticae Dnervnik obsh. vrach. pri imp Kazan Univ, 1894, II, 69-76. Hektoen, L., a case of multiple foci of interstitial myocarditis in hereditary syphilis. Tr. Path, and Bact., Edinburgh and London, 1894-96, III, 472-476. 210 THE SURGERY OF THE HEART Fraenkel, a., Demonstration eines preparates von herzsyphilis. Verhandlg. Deut. Berlin. Med. Gesellschajt, 1895, XXV, 55-57. Israel, O., Ein fall von syphilitischer endocarditis. Berlin Klin. Woch., 1895, XXXII,' 792. Jacquenet, R., La syphilis du coeur. Gaz. des Hop., Paris, 1895, LXVIII, 917-925. LooMis, H. P., Syphilitic lesions of the heart. Am. Journal Med. Sc, Philadelphia, 1895, 337-340. O'DoNOVAN, C, A case of syphihtic endocarditis causing mitral valve insufficiency. Maryland Med. Jour., 1895-96, XXXIII, 179-182. Mracek, F., Klinisches zur herzsyphilis. Med. Chir. Centrhl., 1895, XXX, 337-340. Rendu, Note sur un cas de syphilis du cceur accompagne de pouls lent permanent. Bull, et Mem. Soc. Med. d. hop., Paris, 1895, 3 s., XI, 381-386. Sifihde del cuore. Gazz. d. osp., Milano, 1895, XVI, 1137-1145. VoRMKOFF, v., Doa sluch lues cordis. Vratch. Zapiski, Mosk., 1895, II. Wetchtomoff, E., On syphilis of the heart, case of myocarditis syphilitica and reply of Dr. Kazenskon, Moskva, 1895. De Massary, E., Un cas de syphilis cardiaque. Bull. Soc. Anat., Paris, 1895, LXX, 594-597- Baccarani, U., Le syphilide de cuore. Rasegne di Soc. Med., moderne, 1895, X, 223, 227. Matani, F., L'aritma sifilitica. Progresso Med., Napoli, 1895, IX, 230-235. Smith, R. S., A case of cardiac disease with liver enlargement, illustrating the probable effects of syphilis on the heart. Clin. Jour., London, 1895-96, VII, 145-149. Generisch, a., a very singular case of tuberculosis and gumma- tous disease of the muscles of the heart. Orovosi Hetil. Buda- pest, 1896, XL, 632-635. Duckworth, D., A case of sudden death due to cardiac syphiloma. Tr. Plin. Soc, London, 1896, XXIX, 7-10. Lazereff, N. S., Combined diseases of the valves of the heart of Plate XXV. X 500. Cysticercus, (Bladder Stage). (Chapter on Animal Parasites.) SYPHILITIC GUMMATA 211 syphilitic origin. Voyenno Med. Journal, St. Petersburg, 1896, CLXXXVI, I sect., 415-433. CoGGERSHALL, F., A case of syphilis of the heart. Boston Med. and Surg. Journal, 1896, CXXXV, 593-599. Gerhardt, C, Pericarditis syphihtica. Charite Ann., 1896, XXI, 153-156. Lazarew, N. S., Deux cas de syphihs du cceur. Presse Med., Paris, 1896, 676. Phillips, S., Syphilitic diseases of the heart wall. Lancet, London, 1897, 1, 223-231, Cardiac syphihs in the production of cardiac disease has received less attention than it deserves. " Year book," Gould, 1897, p. 147. Cardiac syph. etc. (as above). Bryant, Sudden death; syphihtic fibroid disease of the heart. Guy's Hospital Gaz., London, 1897, XI, 53. Herrick, J. B., Syphilis of the heart. Fort Wayne Med. Jour., Mag., 1897, XVII, 61-65. Grossman, Uber die acquirirte syphilis des herzens. Milnch. Med. Woch., 1897, XLIV, 473, 506, 522. Gespil, Herz syphilis. Jahrb. d. gesellsch. /. Med. und Heilk. in Dresden, 1897-98, 43. Lecount, E. R., Gummata of the heart in a case of congenital syphihs. Journal Am. Med. Ass'n., 1898, XXX, 181. Jaccoud, Cardiopathie syphilitique. Rev. Prat, de Trav. de Med., Paris, 1898, LV, 249-251. Preis, N., Syphilis of the heart. Meditisma, St. Petersburg, 1898, X, 41, 4, 19. Adler, I, Observations on cardiac syphilis. N. Y. Med. Journal, 1898, LXVIII, 577-584. Babes, Die syphilis des herzens. Heilkunde,Wien, 1898-99, III, 191. CoMBENALE, Role dc I'heredo-syphilis dans I'etiologie de certaines cardiopathies valvulaires. Echo Med. de Nord, Lille, 1900, IV, 419-421. Leared, Aortic valve disease apparently caused by syphilis. Jacquinet refers to rarity of cardiac syphilis up to this time, only 102 cases reported and of these only sixty-one trustworthy and complete. Gaz. des Hop., No. 3, p. 917. CHAPTER XIV GANGRENE Gangrene of the heart is the least frequent of the dis- eases herein mentioned. Historical (1850-1903). — The first case reported is by Gaullay, 1807; it is hardly more than a casual mention. Ken- nedy (1824), however, is more explicit in his report of a case of acute carditis terminating in gangrene of the heart, with illustrations of the same lesion determined by other forms of disease. Cruveilhier (1850) made some interesting observations upon its pathology and maintained that it could occur as an independent disease. Young (1868) reported a case of gan- grene of the heart and Oulmout mentioned an eruption simu- lating rubeola, cyanosis, and oedema in a case of gangrene of the heart. Gesland also reports a case of cardiac gangrene. BIBLIOGRAPHY Gaullay, Jour, de Med. Chir. Pharm., Paris, 1807, XIII, 7-19. Kennedy, London Med. Reporter, 1824, 4 s., I, 269, 284. Cruveilhier, Bull. Soc. Anat., Paris, 1850, XXV, 167. Young, D. S., Cincinnati Med. Repository, 1868, 1, 137, 143. Oulmout. 212 CHAPTER XV BENIGN TUMORS— FIBROMATA, LIPOMATA, ANGEIO- MATA, RHABDOMYOMATA, MYXOMATA, POLYPI FIBROMATA. — Of tumors of the heart, the most common are the fibromata, but while fibroid degeneration of the heart is frequent and may involve a part, or all of the muscular structures, it rarely, if ever, takes the form of a tumor. The latter may develop in any of the heart's structures, principally in the muscles. Historical (1852-1903). — Gull (1852) found a fibroid tumor attached to the muscular tissue of the left ventricle of the heart of a sheep. Elliott (1856) found one in the right ventricular wall of a human heart. In this case there were a sacculated aneurysm and dilatation of the heart as a result of pressure. Wilks (1856) discovered a fibrous growth in the sseptum ventriculorum of the heart. Hitchcock (1856) re- ports three such tumors in the right ventricular wall, associ- ated with hypertrophy of that wall. Wagstaff (1871) records cases of cardiac fibroid and Laid- ley ( 1879) gave a report of a tumor in the cardiac wall. Meigs ( 1881 ) recorded a case in which a heart clot occurred as a con- sequence of ur?emic convulsions and tumors in the heart. Gairdner (1893) reports a very interesting case of obstruc- tion of the right auriculoventricular orifice caused by a tumor in the auricle acting as a ball valve, during the direct current from the auricle to the ventricle and without other apparent disease of the valve or the heart. He gives clinical comment on diagnosis and prognosis. 213 214 THE SURGERY OF THE HEART Latnella (1896) records a pedunculated fibroid in the heart, and Cesaris-Demie (.during the same year) reported multiple fibroids of the heart, while Jachia also made an exten- sive contribution to the study of fibroid tumors of the heart. Crawford (1897) records a case of fibroid tumor of the pulmonary valves and Raw (1898), one in the right auricle of the heart with rupture of the inferior vena cava. Knox (1899) records a case of supra-arterial epicardial fibroid nodules. BIBLIOGRAPHY Gull, W., Guy's Hosp. Report, London, 1852, SS, VIII, 14^; I pi. Elliott, New York Medical Times, 1856, V, 236-8. WiLKS, Tr. Path. Soc., London, 1856-57, VIII, 150-155. Hitchcock, H. O., Boston Med. and Surg. Journal, 1856, LIV, 250-253. Wagstaff, W. W., Tr. Path. Soc., London, 1871, XXII, 121- 124. Yeo, J. B., Case of cardiac tumor of the cavity of the left ven- tricle. Tr. Path. Soc., London, 1875, XXVI. 52-55 ; 2 pi. McCracken, J. W., Tumors in the cavities of the heart. Ohio Med. Rec, Columbus, 1876. I, 114-116. Bramwell, B., Tumor of the exterior of the heart. Brit. Med. Journal, London, 1877, I, 815. Laidley, St. Louis Med. and Surg. Journal, 1879, XXXVI, 264-266. Meigs, A. V., Tr. College Phys., Philadelphia, 1881, 3 s., V, 19-27. Roberts, J. B., Tumor of the heart. Tr. Coll. Phys., Phila- delphia, 1 88 1, 3 s., V, 27. Ferguson, Aneurysmal dilatation of the heart and mitral ste- nosis; fibroid induration. Med. Rec, New York, 1883, XXIV, 75. BENIGN TUMORS 21 5 Turner, F. C, Multiple growth in the myocardium. Illus. Med. Nczvs, London, 1888-89, I> 45 5 i pl- Loom IS, H. P., Peculiar tumors in the heart muscle. Med. Rec, New York, 1889, XXV, 106. Gairdner, Edinburgh Hospital Rep., 1893, I, 221-234; 2 pi. Crawford, Tr. Path. Soc, London, 1897-98, XLIX, 37-41. Raw, British Medical Journal, London, 1898, II, 1335. Knox, Jour. Exp. Med., New York, 1899, IV, 245-260; 3 pi. Traina, R. I., Tumor primitivi del cuore. Clinical Medccine Ital, Milan, 1902, XLI, 65-81 ; i fig. LIPOMATA (1886-1903). — Lipomata of the heart are comparatively rare. They may be fibromatous or myxomatous, single, multiple, or diffused. They are connected, as a rule, with the fat about the base of the heart, or form upon its ex- ternal surface. They may, however, form independently of the fat in the heart, as elsewhere, and may be associated with any other form of new growth, or with general fatty degeneration of the heart. Lipomata may form upon the endocardium or pericardium, either with a broad base or pedunculated. If pedunculated lipomata form upon the endocardium they may swing into any of the cardiac cavities, or into the aortic orifice and occlude one or more of them ; if upon the pericardial sur- face, they will move freely within the pericardial space and if large enough, produce serious or fatal trouble from pressure alone. They may form within the wall of the heart and un- dergo fibrous or caseous degeneration. Any form of new growth may produce death from pressure alone, or by inter- fering with the heart's action in general. Lipomata are benign and rarely, if ever, disappear spon- taneously. They are usually found after middle life, more fre- quently in women than in men, and do not recur when removed. Banti and Handford (1886) each record a case of primi- tive lipoma of the heart, while Kolisko (1887) observed two, 2l6 THE SURGERY OF THE HEART one of which was congenital. Pietroni (1887) and Pelroethi (1897) also contribute interesting studies of lipomatous growths of the heart. BIBLIOGRAPHY Banti^ G., Spcrimcntale, Firenze, 1886, LVIII, 237-241. Hanford, H., Tr. Path. Soc, London, 1886-87, XXXVIII, 108, 112. KoLOSKO, A., Med. Jahrb., Wien, 1887, N. F., II, 135-158; I pi. Pietroni^ P., Boll. d. sez. d. cult. d. Sc. Med., N. S., Acad. d. fisiocult di Siene, 1887, VI, 101-105. Pelroethei, L., Sperimentale, Arch, etc., biol. Firenze, 1897, LI, 89-98. ANGEIOMATA ( 1 887-1 903 ).—Angeioma of the heart is infrequent. It is formed of blood and is known as an erectile or a vascular tumor. It is cancerous when the alveolar spaces communicate with one another. Angeiomata develop upon the external or internal surfaces of the heart indifferently and in the same manner; they may be interstitial and of any size or number. The projection may be outward or inward; in point of fact their course is similar to that of any other kind of cyst. Angeiomata may rupture in one or all of the chambers of the heart, or into the pericardial sac. If they be large, death will ensue, especially if the rupture be into the heart's chamber, clots being carried into the general circulation. If the rupt- ure of a large tumor be external, the pressure alone may be sufficient to produce death. Smaller ones may rupture in either direction without causing dissolution ; usually, however, fatal results ensue because of an impaired heart wall, resulting from a pathologic condition existing prior to, and at the time of rupture. Neoplasms in any part of the body are more fre- BENIGN TUMORS 21/ qiient in women and therefore, cardiac angeiomata are sup- posed to be so. Sussman (1887) reports an interesting case, in which he found cardiac angeioma, as does Mann. Schmalts (1888), Miura (1889), Preisz (1890), and Von Etlinger (1890), each record a case of angeioma of the heart, while Birchoff (1893) reports a case of a cavernous angeioma of the heart, and Smith ( 1894) records one of the right auric- ular wall, terminating in rupture. BIBLIOGRAPHY KiEwiET^ Nederl Tjdsch, V. Geeneeske, Amsterdam, i' XXII, 550-554- SussMANN, Miinr/z. Med. IVoch., 1887, XXXIV, 991-1014. Mann, Jahrb. de gesellsch. f. Nat. u. heilk., Dresden, 1887-88, 3-14. Schmalts, D^w^. Med. IVoch., 1888, XIV, 921-925. Miura, Arch. f. Path. Anat., Berlin, 1889, CXV, 355 ; i pi. Preiz, Heit. z. Path. Anat. u. Allg. Path., Jena, 1890, VII, 245-298; I pi. Von Etlinger, Arch. f. Kinderheilk., Stuttgart, 1890-91, XII, 348-359- Birchoff, Balnitsch Gaz. Botkina, St. Petersburg, 1893, IV, 673-676. Smith, Med. Rec, New York, 1894, XCVI, 5-9. Raw, Arch. f. Anat., Berlin, 1898, CLIII, 22-2^; i pi. RHABDOMYOMATA. — Rhabdomyoma is a rare form of primary myoma characterized by the presence of striated mus- cular fibre. It is found in the muscular tissue of the heart upon the endocardial or pericardial surface or within the car- diac walls. Rhabdomyoma is single as a rule, but may be multiple. 2l8 THE SURGERY OF THE HEART and in either event causes serious trouble by its presence, like other forms of new growth. BIBLIOGRAPHY Seiffert. — Uber congent. Rhabdomyomie des herzens. \'erhandl. d. Deutsche Patt. Gesellsch, Berhn, 1901, III, 64, i. abb. MYXOMATA. — Myxoma is a mucous tumor composed of connective tissue, gelatinous in character, containing intercel- lular substance in which are scattered peculiar branched, or stellate cells. It attacks the epithelium and connective tissue, involving one or both, and may be single or multiple, and vary in size and shape. Its location may be in any portion of the heart, and it may produce serious trouble from its size or location, or it may rupture into the cardiac cavities and thence discharge into the general circulation, or into the pericardial space, and so cause death by pressure alone. Berteusen (1893) reported a case of myxoma of the left auricle, adding much information as to their formation. Robin (1893) reported a case of myxoma of the heart. His is among the earlier reports of this rare condition; not till 1897 did Petroff report a similar case. BIBLIOGRAPHY Robin, A., Arch, de Med. Experim. et d'arch. Path., Paris, 1893, 802-806. Petroff, N., Balnitsch, Gaz. Botkina, St. Petersburg, 1897, VII, 745-751- Berteusen, Vratch, St. Petersburg, 1893, XIV, 145-181. Plate XXVI. X 180. Trichina Spiralis, (Encysted in Human Voluntary Muscle), X 180. Trichina Spiralis, (Free), (Chapter on Animal Parasites.) BENIGN TUMORS 219 POLYPI (1689-1903). — Polypoid growths may develop upon any part of the endocardium or at any point upon the ex- ternal surface of the heart. They are benign when composed of fibrous tissue, and slow in their development. When of rapid growth, they are associated with sarcoma and myxoma. They are sometimes called oedematous fibroid, and may have a broad base, or be pedunculated. They may become detached in part or as a whole, and when upon the endocardium in such case occlude one or more of the cardiac orifices or enter the general circulation, or both, and act like an embolism. Polyps within the cardiac chambers were recognized as early as 1689 by Pretten and by Rossen (1693), Behrena (1724) and Klotzsah (1727), the last-named investigator hav- ing found them in a subject who had succumbed to pneumonia. The most interesting of the earlier observations, however, were made by Huxham (1732) of polypi, taken out of the hearts of several sailors arrived at Plymouth from the West Indies. Their development was probably due to blood changes, resulting from the habits of the sailors, and their pro- longed stay in a tropical climate. Nothing has since devel- oped to indicate anything of an epidemic nature in their forma- tion. Templeman (1756) reported a polyp in the heart of a subject who had scirrhous tumor of the uterus. Sherrill (1820) gives a detailed report of a polyp found in the heart of a child eight years old. Le Groux (1827) made an exhaustive research into the causation and character of cardiac polypi. He was followed by Barrera (1829) who failed, however, to add anything new to the knowledge already obtained. Harty (1830) ventures to speak of polypi of the heart as an idiopathic affection and as a cause of death. Za- briskie ( 1835) reports a case of polyp in the heart of a woman with death during labor. Henderson (1843) mentions a diseased heart with a globu- lar polypus in the right auricle. Aran (1844) one in the ven- 220 THE SURGERY OF THE HEART tricle extending into the pulmonary artery and obstructing it. Harpur (1845) reports a similar one. Fletcher gives a most interesting case of this character in which an organized polyp of the heart grew from the left auricle and hung from the left ventricle, giving rise to a peculiar bruit, distinctly audible some yards from the patient. This was verified by the autopsy. ]McCormick (1864) wrote an able essay on the effect of blisters in the formation of polypi, and McGillivray (1866) described fibrous polypi in the right heart, accompanied with tricuspid regurgitation, in a case of double pneumonia. Douglas (1868) and Gaskoin (1869) each report a polyp in the left auricle. Hill ( 1875) reports a case of cardiac polypus in connection with malaria and Ribail (1883) one in a case of pulmonary tuberculosis, associated with parenchymatous ne- phritis. In the case of Aikins (1888), death was sudden from a cardiac polypus. Voeleker (1892) reported a case of intra- auricular cardiac polypi. BIBLIOGRAPHY Pretten^ Wittenbergse, 1689. RossEN, A., Lund Bat., 1693. Behrena^ Herrn Geistlichen. Saml. v. Nat. ii. Med. Gesch., Leipsic u. Budissin, 1724, XXIII. 307-316. Klotzsch, Erfordise, 1727. Grateloup, De polypo cordis Argentorati, 1731. HuxHAM, J., Phil. Tr., 1732-44, London, 1747. IX, 135. Rausch, De polypo cordis Halse, Magdeb., 1741. Van der Gryp, De polypo cordis Lngd Bat., 1742. Templeman, P., Phil. Tr., 1743-50, London, 1756, \^I, 1020- 1022. Uhlich, Beobachtung von polyposen concrementen des herzen allg. Med. Am., Alten, 1812, 336-341. ScHMELCHER, Dc polypis cordis Landshuti, 1819. BENIGN TUMORS 221 Sherrill, H., Med. Reposit., New York, 1820, n.s., V, 302- 305- L'Egroux, La Vie, Paris, 1827. Barrera, Ann. di mcd., Milano, 1829, XLIX, 419-446. Caron, Tumeur polypiforme developee dans I'oreillette gauche et plongeant dans I'orifice aiiriculo-ventriculaire. Harty, W., Dubl. M. Tr., 1830, n.s., I, 218-255. Bland, Memoire sur les concretions fibrineuses polypiformes dans les cavites du coeur. Rev. Med. franc, et etrang., Paris, 1833, IV, 175, 333. Bronc, Observation sur un signe diagnostique particulier d'une concretion polypeuse du coeur. Jottr. hehd. d. progr. d. sc. et inst. Med., Paris, 1834, I, 422-429. Zabriskie, J. B., Am. Jour. Med. Sc., 1835, XVI, 375-379. RoETTEKEN,, Dc cordis polypo. Wirceburgi, 1836. Maignien, Des polypes du coeur. Strasburg, 1840. Lehmann, De cordis polyporum natura et origine. Berolini, 1840. Perrier, Observation de concretions polypiformes ou poly- pes du coeur. Rec. de Mem. de Med. Mil., Paris, 1842, LIII, 50-62. Henderson, Loud, and Ed in. Month. M. J. Sc, 1843, m' 808-816. Aran, Arch. Gen. de Med., Paris, 1844, II, 461-466. DuNGLisoN, R., Heart polypus of Cycl. Pract. M. (Twee- die), Philadelphia, 1845, II' A^9- Harpur, J., Boston Med. and Surg. Jour., 1845, XXXII, 377. Morrell, G. C, Polypus of the heart. Nezv York Med. Jour., 1846, VI, 373. Fredault^ Des polypes du coeur. Concretions polypiformes; caillots; recherches sur leur organisation. Arch. Ghi. de Med., Paris, 1847, H' 63-71. Fletcher, Prov. Med. and Surg. Jour., London, 1851, 686- 688. MoppEY, Zur dianostik von Herz polypen. IViith. d. Vadisch. aerztl. Ver., Karlsruhe, 1852, VI, 113-117. 222 THE SURGERY OF THE HEART Xeild, J. E., Polypoid growth of the heart. Lancet, London, 1852, II, 548. Hudson, A., A case of fibrinous polypi of the heart. Dublin Hosp. Gaz., i860, n.s., VII, 83. McCoRMiCK, Dublin Med. Press, 1864, II, 312. McGiLLiVRAY, D., Canada Med. Jour., Montreal, 1866, II, 51- 56. Douglas, Edin. Med. Jour., 1868, XIII, 908-916. Gaskoin, Med. Times and Gas., London, 1869, II, 276. Hill, W. H., Indian Med. Gaz., Calcutta, 1875, X, 21 1. Clarke, C. K., A case of cardiac thrombosis or polypus of the heart occurring in connection with pneumonia. Canad. Jour. Med. Sc., Toronto, 1879. IV, 86. RiBAiL, Prog. Med., Paris, 1883, XI, 1056. AiKiNS, W. H. B., Canad. Pract., Toronto, 1888, XIII, 319. VoELEKER, A. F., Tr. Path. Soc., London, 1892-93, XVII, 31-35- Pavlovskava Traisa A.). Symptomatology and cases of polypous neoplasms of left auricle. Bolnitsch. Gas. Bot- kina, St. Petersburg, 1893, IV, 721, 753, 782, 797. Krumbholz, Zur casuistik der gesteilten herzpolypen und der herzel threnken. Ab. und Med. Klin. Zr., Leipsic, 1893, 328-331. Pedunculated thrombi of true polypi of the heart. Russk. Med., St. Petersburg, 1894, XIX, 125-140. Parlowsky, R., Beitrag zum studium der symptomatologie der neubildungen des herzens-polypose ; neubildungen des linken vorhofs. Berlin IVoch., 1895, XXXII, 393-413. Packard, F. A., Specimen of cardiac polypi. Tr. Path. Soc, Philadelphia, 1893-95, 1896, XVII, 85. Carton, J., Polype du coeur gauche avec endocardite articu- laire; insuffisance tricuspide; pleuresie concomitante. Gaz. Med. de Picardie, Amiens, 1897, ^V' 122-124. Seiffert, Ueber congenitale rhabdomyome des herzens. Vcr- handhing d. Dcutsch Gesellschaft Pathologie, Berlin, 1901, III, 64; I Abb. CHAPTER XVI MALIGNANT TUMORS Tumors of the heart may be primary or secondary, malig- nant or benign, and slow or rapid in their development, involv- ing all or any part of the cardiac tissue. There are several varieties of each. SAECOMATA of the heart are very infrequent. They may be primary or secondary. They are composed of embryonic connective tissue with cells varying in character and number, and are very vascular, sometimes pulsating. They seem to be intimately associated with blood-vessels, and are more frequent in men after the age of forty. They are supposed to be of rapid growth in the heart, causing distress and death from pressure alone. They may be cystic and rupture into the cham- bers of the heart or into the pericardial sac and cause death in either event. Fibromatous, diffused, melanotic, spindle, and round-celled varieties seem to attack the heart with equal fre- quency. Historical (1880-1903). — Gross (1880) records one of the first round-celled sarcomata of the heart, and Jacobi (1881), a fibrosarcoma. Broadbent (1881) records a case of sarcoma of the pericardium and Liberius (1883) one of the same character which also involved the bronchial glands. Loomis (1892) reported a diffused infiltrating sarcoma of the heart. Manero (1882) is the only one to record a case of melanoma of the heart. Hektoen (1893) records three specimens of me- tastatic tumors of the heart; ist, a carcinomatous nodule, im- planted in the myocardium; 2d, a sarcoma of the right ven- 223 224 THE SURGERY OF THE HEART tricle; 3d, a primary round-celled sarcoma of the epicardium. Thacher (1895) mentions a case of sarcoma of the heart. Leroux and Meslay (1896) also record a primary sarcoma, and Lambert's (1898) case was a primary sarcoma of the heart. Raw (1898) recorded a spindled-cell fibrosarcoma, three inches in diameter, and adherent to the wall of the right auricle. BIBLIOGRAPHY Gross, W. S., Tr. Path. Soc, Philadelphia, 1880, IX, 9—93. Jacobi, a.. Bull. New York Path. Soc, 1881, 2 s. I, 91-93. Broadbent, W. H., Tr. Path. Soc, London, 1881, 2, XXXIII, 78-81. Manero, E., Gac de I'Hosp., Valencia, 1882. LiBERius, P. F., Med. Pribow K. Mosk. Sbornikin, St. Peters- burg, 1883, Fby P, 32-45. LooMis, H. P., Med. Rec, New York, 1892, XLII, 461. Hektoen, L., Med. News, 1893, LXIII, 571-574. Thacher, J. S., Med. Rec, New York, 1895, XLVII, 283. Leroux and Meslay^ Bull. Soc. Anat., Paris, 1896, LXXXI, 680-685. Lambert, A., New York Med. Journ., 1898, LXVII, pp. 210, 212, 230. Raw, Brit. Med. Joiirn., Oct. 29, 1898. Sterling, W., Sarcome diffus du coeur des reins et de la pro- state. Gazette lek., Warszawa, 1901, XXI, 731-734. CARCINOMATA (1847- 1903). —Scirrhous and encepha- loid cancers of the heart are rare and are found more frequent- ly upon the right side. They may be primary or secondary, usu- ally secondary malignant, and they have been found in intra- uterine life and may occur at any age, but are more frequent in middle life. The nodules are usually situated upon the surface of the heart and may not implicate cardiac fibres. • MALIGNANT TUMORS 22$ Carcinoma is more inclined to produce pericarditis than sarcoma which is more frequent. About fifty per cent, are sec- ondary to disease in other organs or tissues. It is supposed to be more common than tuberculosis of the heart. Andral and Bayle were the earliest writers on cancer of the heart. They reported several such cases. Walsche collected twenty-five cases of cancer of the heart, but, like Andral and Bayle, did not attempt to classify them. The distinctive char- acteristics of malignant growths were not known until after Virchow had made his classification. Until that time, and with a few cases thereafter reported, doubt will prevail as to the true character of the neoplasm. However, they were known to be of both primary and secondary origin. One must of necessity refrain from attempting to classify those of pri- mary origin in the heart, even many of those of secondary ori- gin. The last, however, came before the time of Virchow, who gave them their identity. Ormerod (1847) recorded a case of encephaloid disease of the endocardium and Hewitt (1847) during the same year reported two remarkable cases of encephaloid disease of the heart. In the case of Fletcher (1850) there were copious de- posits of cancerous matter in the heart and left pleural cavity. Wilks ( 1 854-1 85 7) found these masses in the base of the heart. Sibley (1857) recorded a case of endocarditis in the right side of the heart, caused by small cancerous tumors beneath the endocardium, with additional adhesive phlebitis. Fuller (1859) reported a case of encephaloid disease of the heart and right lung, and Wilks found secondary cancer in the heart and intestines. Maxon (1867) observed encephaloid cancer of the heart and scirrhous cancer of the thyreoid gland. DeCosta ( 1880) reported a case of cancer of the heart resulting in cere- bral embolism. 226 THE SURGERY OF THE HEART BIBLIOGRAPHY Ormerod, E. L., Med. Chir., London, 1847, XXX, 39-49. Hewett, p., Med. Chir. Tr., London, 1847, XXX, 1-7. Fletcher^ Prov. Med. and Surg. Jour., London, 1850, 551- 553- WiLKS, Tr. Path. Soc. London, 1854-55, VI, 112-114. AiNSwoRTH, F. S., Cancerous disease of the heart. Boston Med. and Surg. Journal, 1855, LIII, 148. Jackson, Cancerous disease of the heart. Ext. Rec. Boston Soc. Improve., 1856, II, 226. Sibley, S. W., Tr. Path. Soc. London, 1857-58, IX, 128-130. WiLKS, Tr. Path. Soc, London, 1857-58, IX, 87. Fuller, H., Tr. Path. Soc, London, 1859-60, XI, 78-80. Also Abstract, Lancet, London, 1860-61, 495. WiLKS, Lancet, London, 1861-62, p. 254. Peacock, T. B., Cases of cancerous deposits in the heart. Tr. Path. Soc. London, 1865, XVI, 99-120. Maxon, Tr. Path. Soc. London, 1867, XVIII, 38 to 42. Hun, E. R., Cancer of the heart. New York Medical Journal, 1868, VII, 106-116. Peacock, T. B., Adventitious product in the heart. Syst. Med. (Reynolds), London, 1877, IV, 165-181. DaCosta, J. M., Philadelphia Medical Times, 1878, VIII, 266. Ingram, T. D., Cancerous heart ( ?) with dilated right ven- tricle; sudden death with symptoms of angina pectoris. Tr. Path. Soc. Philadelphia, 1878-79, VIII, 59-64. DaCosta, J. M., Cancer of the heart. Med. Gazette, New York, 1880, VII, 273, 275. Cornil, G., Paris, 1902, p. 124. CoRNiL, G., Etude sur le cancer du coeur. Paris, 1902, No. 283, 124 p. ^ Cornil, G., Etude sur le cancer du coeur, Paris, 1902, No. 282 124 p. CHAPTER XVII ANIMAL PARASITES— PARASITIC FUNGI— BACILLI Echinococcus. — About three and one-half per cent, of all cases in man are found in the heart (Cobbald and Davaine) . It is generally multiple and may be within the myocardium, or be- neath the pericardium or endocardium in the form of a tumor. Sometimes the sac is pedunculated and is allowed to swing within one or more cavities of the heart, and even in the greater vessels. It may rupture and pass into the general circulatory system, acting as emboli. Rupture may also take place into the pericardial sac. Echinococcus is the smallest tape-worm known. It needs to be magnified in order that its structure may be made out. Except to one trained in making examinations it is very hard to distinguish the Cysticercus ordinarily found in man, from many individuals of the dog tape-worm. Measly beef and pork are caused by cattle and hogs being infected with cysticerci which have become encysted. The cysts in pork can be easily seen with the naked eye. Corned beef very frequently is measly. This condition can be easily detected by allowing a piece to dry, when the calcareous shells of the cysts may be seen as small white spots. The heart may become infected by carrying dirty hands to the mouth, or from the cysts of meat being broken in the mouth and the cysticerci penetrating the oesophagus and thus entering the heart. Historical (1718-1903). — Price (1821) records a sudden death in which an hydatid cyst was found in the substance of 227 228 THE SURGERY OF THE HEART the heart. Evans (1832) records a similar case, and WilHams (1834) found one in the heart of a child. Vines (1845) found the cysts in great numbers, floating freely in the cavities of the heart. Budd (1858), Coote (1854), Wilks (1859), Rosi (1866), and Barclay (1866) found them in the lungs, and Budd discovered them in the branches of the pulmonary artery. Kelly and Maon each reported cases in which there was obliter- ation of the coronary arteries from pressure of the cyst. Pea- cock (1873), Goodheart (1876), and Guglielani each report cases. Goodheart cured his by aspiration. This was in 1876, so it can be classed among the earlier operations upon the heart. Arnould (1881), Renaul (1882), Knight (1886), and Martin Durr ( 1889), report cases of sudden death as result of rupture of the cyst. Demantke (1895), Knaggs (1896), An- dreini (1897), Guillemand (1897), and Jameson (1897) each report cases of this parasite in the heart, one of which ruptured in the right auricle. The presence of entozoa in the heart is little credited at the present time. Osborne (1847) reported a case in which he found worms in the heart of a dog with symptoms of hydro- phobia. Simpson (1851) also reports having found parasites in the heart of a dog. Somerville made the same observations and Morgani, Du- puytren, and Trotter each report such cases. BIBLIOGRAPHY KoRTHOLT, Von, Egeln odcr wiirmcr so im Hertzen einer Frau gefunden worden. Sand. V. Nat. W. Med. Gesell., 1717-1S, Breslau, 1718-20, 1218-1221. Trotter, Med. and Chcm. Essays, 1795, p. 123, case of a blue boy. Price, D., Med. Chir. Tr. London, 1821, XI, 274-76. Plate XXVII. X 1000. OlDIUM. X 720. Actinomyces. (Chapter on Parasitic Fungi.) ANIMAL PARASITES— PARASITIC FUNGI— BACILLI 229 Evans, H. R., Med. Chir. Tr. London, 1832, XVII, 507-11 ; i pi. DupUYTREN, Journal de Corvisart et Lcroux. Tome V. Div., CI, p. 139. Williams, W. H., London Med. and Surg. Jour., 1834-35, VI, 470. Vines, Med. Times, 1845-46, XIII, 28. Griesinger, W., liber acephalocysten am Herzen. Arch. f. physiol. Heilk., Stuttgart, 1846, V, 280-287. Osborne, West. Jour. Med. and Surg., Somerville, 1847, 3 s., VIII, 491- Ward, N., Acephalocyst in the substance of the heart. Tr. Path. Soc, London, 1848-50, I, 225. Moreno, J., Inosperada aparicion de un estado de ansiedad y difficultad en la respiracion, seguio de la muerte a la hora y media; autopsia; quistes, hidatidicos en la ventriculo derecho del corazon. Gaz. Med., Madrid, 1849, V, 35. Simpson, J. Y., Month. Jour. Med. Soc, London and Edinburg, 185 1, XVLLL, 283. CooTE, H., Med. Times and Gaz., London, 1854, VIII, 756. Babington, a cyst connected with the heart opening into the peri- cardium, and causing death. Tr. Path. Soc, London, 1855, VI, 114-117; I pi. ScHUPPERT, M., Mechanical obstruction of the heart, entozoa causing death. New Orl. M. and Hot Spgs. Gaz., 1857-58, IV, 68(^682. BuDD, G., Med. Times and Gaz., London, 1858, XVII, 54-56. Also Abstr. Tr. Path. Soc, London, 1858, XVII, 54-56; also abstr. Tr. Path. Soc, London, 1858-59, X, 80-83. Molland, Cysticerques trouves dans le coeur. Bull Soc. anat. de Paris, 1859, XXXIV, 59. WiLKS, Tr. Path. Soc, London, 1859-60, XI, 71. WiLKS, Lancet, London, i860, I, 446. Rosi, L., Firenze, 1866, XVII, 332-337. Barclay, J. Glasgow Med. Jour., 1866-67, 3 s., I, 426, 431. Oesterlen, O., Arch. j. Path. Anat., etc. Berlin, 1868, XLII, 404-418; I pi. 230 THE SURGERY OF THE HEART Kelly, C, Tr. Path. Soc, London, 1869, XX, 145-1481. Maxon, W., Tr. Path. Soc, London, 1870, XXI, 99. Spencer, W., Binocular cyst in left ventricle of the heart. New South Wales Med. Gaz., Sidney, 1872, II, 307. SoMERViLLE, J. R., CustoiHs Gaz. Med. Rep., 1873-74, Shanghai, 1875, VII, 13-17. HoLDEN, E., Extraordinary case of intracardiac cyst. Am. Jour. Med. Sc, Philadelphia, 1876, n. s., LXXII, 395-98. GooDHEART, J. F., Tr. Path. Soc. London, 1876, XXVII, 72. GuGLiELMi, Jour, de med. et de pharm. de I'Algerie, Alger, 1877, I, 92. Arnould, J., Bull. med. du nord, Lille, 1881, XX, 475-483. Renault, Bull. Soc. Anat. de Paris, 1882, 4 s., VII, 124-26. MosLER, F., Uber Zroparasitare Krankheiten des Herzens. Zeitch, }. kiln. Med., Berlin, 1883, VI, 215, 239. Blaise, Influence disastreuse des parasites et vegetaux sur I'eco- nomie animale, ulceration de I'aorte posterieure, etc. Jour. de med. et de pharm. de VAlgerie, 1883, VIII, 98, 122, 150, 174, 194, 220, 248, 274. Knight, Liverpool Med.-Chir. Jour., 1886, VI, 231. Hadden, W. B., Cyst of the heart. Tr. Path. Soc. London, 1887-88, XXXIX, 79. Martin, Durr, Bull. Soc. Anat., Paris, 1889, LXIV, 131. Demantke, G., Bull. Soc. Anat., Paris, 1895, LXX, 122-125. Knaggs, W. H. E., Lancet, London, 1896, I, 29. Andreini, a.. Bull. Soc. Rom. per gl. Stud. Zool., Roma, 1897, VI, 227-233. Guillemand, B. J., South African Med. Jour., Capetown, 1897-98, V, 291. Jameson, L, Australia Med. Gaz., 1897, XVI, 598. Stoenescu, N., Spitalul Bucuresci, 1898, XVIII, 169, 173. Peacock, T. B., Tr. Path Soc. London, 1873, XXIV, 37. Miljnikoff-Razvelenkoff, Med. Oh., Moskow, 1891, XXXVI, 259, 262. FiRHET, Acad. Royal de Mdd. Belgique, Bruxelles, 1895, 4 s., IX, 394-398- ANIMAL PARASITES — PARASITIC FUNGI— BACH, I,T 23 I Railliet et Moret, CompL Rend. Soc. Biol., Paris, 1898, 10 s., V, 402-404. Giordano, Gazz. d'osp., Milano, 1898, XIX, 1566-1568. Cysticercus (1852-1903) is of two forms, Saginata and Solium. It is more frequent in India and England, but is found in all civilized countries. It is found in the muscles, liver and lungs of the ox. The urinary bladder is its most frequent location in man. It has also been found in the lung, liver, kidney, eye, brain, and heart of man. Taenia Saginata is a yellowish, soft, flattened worm vary- ing in length from one-fortieth of an inch to twenty feet. The great variation in length is due to the fact that the worm grows in length by fission, or in segments, and these remain attached to each other, and continue to grow at the head end until they are found in a large mass, which, when straightened out is often very long. The head is about one twelfth of an inch in diameter, without beak or booklets and has a small proboscis. There is a muscular sucker in each of the four corners of the head, and from each sucker runs a water vascular canal. The round opening in the centre of the head is surrounded by the canals into which the canals from the suckers open. From the circular canal two longitudinal branches continue, one down each side of the various segments. (Examine the fully ma- tured proglottides, as they are arranged in a row. Small pa- pillae with central openings may be observed alternating irregu- larly on each side of the ribands, a little below the centre of the segment. Running down each side of the flattened segments, which are square, or longer than they are broad, is the branch of the water vascular canal, while at the front part of each seg- ment runs a transverse connecting branch.) By plunging the living worm into a solution of carmine, a most beautiful injection of the water vascular system may be obtained. The uterus is very much branched, the diverticul?e dividing dichotomously. The testes consist of a convoluted 232 THE SURGERY OF THE HEART tube placed in the anterior part of the segment, from which leads a duct ending in a cirrhus, or penis, which may, in some cases, be seen protruding through the genital pore. Close to this is the opening of the vagina, and near the posterior part of the segment are a couple of vitelline glands. Each strobilus consists of three or four thousand segments, those sexually matured commencing at or about the four hundred and fiftieth from the head. The cystic form is seen in beef as small yellow- ish spots, which are especially numerous in the thin curved muscles of a round of beef. Taenia Solium. — Taenia cucurbitina or vulgaris is the form which is seen most commonly in Germany. The cyst form — Cysticercus-cellulosse — occurs in pork, where it gives rise to the so-called measly condition. A similar cystic form is met with more rarely in man, in the subcutaneous areolar tissue, between muscles, and in the eye and brain. As in the taenia mediocanellata, the strobilus is composed of head, neck and proglottides. The worm is several feet in length and consists of about twelve hundred segments. There are four suckers around the head, arranged below a well-marked proboscis or rostellum. The proboscis is armed with two rows of hooks, the anterior of which is the larger ; but all of them are consid- erably larger than the booklets of the taenia echinococcus. The water vascular system near the head is double, and is similar to that met with in Taenia Mediocanellata, and may be injected in the same manner. The segments are square or oblong. The uterus, or more properly speaking, the ovary, has a number of lateral branches (seven or ten), which again divide, but not nearly to the same extent as in Taenia jMediocanellata. The genital pores of the cirrus, which alternate regularly, should also be examined. The use of uncooked meat, soiling of the hands by work- ing or handling dirt in which the fasces of human beings, do- mesticated animals and fowls may have been deposited, are fruitful sources of infection. Persons who have harbored the ANIMAL PARASITES-— PARASITIC FUNGI — BACILLI 233 mature form of the tape-worm, have been known to infect themselves by the hands coming in contact with the anus in sleep, or at other times, or by searching in the deposits for seg- ments, etc. Cysticerci have been known to invade all parts and organs of the body. Cysticercosis of the heart is comparatively rare but by no means unknown, as is shown by report of cases. It is quite probable that some cases diagnosticated and reported as hydatid cysts of the heart, have been cases of cardiac cysticercosis. Lendet (1852), Laure (1869), Gibbs (1872), Frank (1879), Joso (1883), Vitto (1884), Meljnikoff (1891), Firhet (1895), Giordano (1898), Railliet (1898), and Moret and Stoneson all give reports of having found the cysticercus in the heart of man. BIBLIOGRAPHY Lendet, Soc. de hioL, 1852, Paris, 1853, IV> 141-146; also Bull. Soc. Anat. de Paris, 1852, XXVII, 469. Laure, Lyon Med., 1869, II, 386, 389. Gibbs, W. R., Tr. South Carolina Med. Soc. Charleston, 1872, 86-88. Frank, E., Allg. Wien Med. Ztg., 1879, XXIV, 376. Joso, Gazz. Med. de Nantes, 1883-84, II, 124. ViTTO, Gior. internaz. de so. med., Napoli, 1884, No. VI, 629, 642. MiLjNiKOFF, Razvelenkofj Med. Oh., Moskow, 1891, XXXVI, 259- 62. Firhet, Acad. Royal, de Med. Belgique, Bruxelles, 1895, 4 s., IX, 394-398- Railliet et Moret, Compt. Ren. Soc. Biol., Paris, 1898, 10 s., V, 402-404. Giordano, Gazz. d'osp., Milano, 1898, XIX, 1566-68. Trichina Spiralis — The presence of this parasite in the car- diac tissues is rare, especially in the human heart. It is a nematode, commonly found in the pig, encysted in the muscles 234 THE SURGERY OF THE HEART of the neck, shoulders, back and diaphragm. The female is larger and more numerous than the male and when found in the heart is of secondary origin, having escaped through the alimentary canal, into which the parasite has been taken with infected pork. Paragonimus Westermani. — The distoma Westermani is a trematode found in Asia, but now being carried to all sections of the world, attacking the stronger of mankind. It is found in the heart, lungs, brain, liver, and other organs of man, and animals in general, being carried into the stomach with food and water, and into the lung with air. It penetrates the tis- sues and finds its way into those of the cardiac system. Nod- ules are formed, generally near the base of the heart, and as a rule contain a male and a female parasite. Distoma Wester- mani is often confounded with tuberculosis, especially if the lungs are involved. PARASITIC FUNGI.— Mycoses of the heart constitute the fungoid neoplasms, showing an abnormal growth of lymphatic glands, caused by pathologic microbes (bacterial or parasitic) in the organism. They may occupy a part or all of the endo- cardial or pericardial surface of the heart, or may be inter- stitial ; however, this is exceedingly rare as compared with the other two varieties, which themselves are rare. The true character of the earlier cases reported has not been well estab- lished. This is also true of many of the more recent reports. Many of them were, no doubt, parasitic, possibly cysti- cercus, or trichina hydatids being more frequent and generally known. Julia (1846) recorded cases in which he found vegetations upon the valves and inner walls of the heart. Bertin (1857) found a case in which there were adhesions of the heart to the pericardium as the result of vegetations. Blanchez (1875) reports a case of a primitive form of vegetation upon the endo- cardium. Desjardins-Beaumetz (1877) noted a case in which the vegetations were upon the endocardium about the orifice of ANIMAL TARASITES— PARASITIC FUNfil — BACILLI 235 the pulmonary artery. Williams (1884) reported vegetations upon the mitral valve, with multiple embolisms and consecutive aneurysmal dilatation of arteries. Meigs (1897) mentions fungous excretions on the valve of the aorta. Actinomyces was discovered by Langenbeck. It is a vege- table parasite, occasionally found in the heart. It may be pri- mary or secondary. The infection of the heart is usually from the left lung, as it is more frequently affected than the right. The nodules are threadlike, pearly or yellow, and from one- half to two millimetres in diameter. They are star-shaped and composed of club-shaped ends. The branching, segemented mycelium is diagnostic. It is not so serious if only the external surface of the heart is involved. The nodules undergo fatty degeneration and cause abscesses, which may rupture into the cardiac cavities, or into the pericardial sac. Carnivorous animals seem to be immunized to this disease. Infection is by eating and drinking food, and by inhalation of air. Macroscopically it can only be diagnosticated by the pres- ence of yellow seed-like bodies which may be seen by the eye, and a greasy feel to the sense of touch. Aspergillus is a vegetable parasite, was discovered by Vir- chow in 1856. There are three varieties: (a) Aspergillus fumigatus. (b) Aspergillus niger. (c) Aspergillus flavus. Either one may be found in any part of the cardiac tissue of man or beast. The most dangerous of the three is Aspergillus fumigatus. It is green in color. The conidia are generally colorless, round and smooth, and without a membrane. It grows best in an atmosphere of thirty-seven to forty degrees, centigrade. Aspergillus flavus is greenish yellow in color. The sclero- tia are very small and black. It grows best at about twenty- eight degrees centigrade. Aspergillus niger is very malignant, and brownish black in color. The fruit bearers are globular, sterigmata long and branching; conidia round and black, or nearly so; sclerotia 236 THE SURGERY OF THE HEART brownish, and about the size of a rape seed. Best temperature for its growth is about thirty-five degrees centigrade. Oidium albicans is a vegetable parasite which has but seldom been found in the heart. It forms delicate horizontal fila- ments, which are apparently homogeneous in structure, and from which short articulated pedicles take their rise. The up- permost cells of these pedicles become expanded into oval bodies, which fall off, germinate, and become filaments. It is generally found growing in tangled masses, like minute bunches of mistletoe, mixed with the debris of scattered spores, cells of the leptothrix, and epithelial scales, but if separate filaments are followed out, such forms as these, which are rep- resented, may easily be obtained (Clark). BIBLIOGRAPHY Julia, Jour, de Med. de Lyon, 1846, X, 405-432. Bertin, Bull. Soc. Anat. de Paris, 1857, XXXII, 214. NiCAiSE, Thromboses de I'artere pulmonaire avec un kyste puru- lent du cceur et des ossifications de la pie-mere. Bull. Soc. Anat. de Paris, 1863, XXXVIII, 405. Jacques, Cas d'affection organique du coeur, d'endocardite chro- nique avec vegetations sur la valvule sigmoide de I'aorte. Am. Soc. d. Anat. Path, de Bruxcllcs, 1875, XXVII, 134- 137- Petres, Note sur la structure des vegetations globuleuses du coeur. Bull. Soc. Anat. de Paris, 1875, 127-29. Balzer, Vegetations globuleuses du coeur. Bull. Soc. Anat. de Paris, 1875, I> 649-652- Blachez, Endocardite primitive a forme vegetante. Bull, et mem. Soc. Med. d. hop. de Paris. 1875, 2 s., XI, 297. Dujardin-Beaumetz, Bull, et mem. Soc. Med. d. hop. de Paris, 1877-78, 2 s., XIV, 147, 152. Letulle, Vegetations globuleuses du coeur, etc. Bull. Soc. Anat. de Paris, 1880, LV, 383-388. Plate XX VII [ ^ / \>L - ^ < ( > I V X 1000. Bacillus QiDEiLXTis -\Ialignl \ \ ^-i X 1000. Bacillus TvpiioinLs. (Chapter on Bacilli.) ANIMAL PARASITES — PARASITIC FUNGI— BACILLI 237 Suzanne, G., Retrecissement aortique par vegetations des val- vules sigmoides. Jour, de Med. de Bordeaux, 1884-5, XIII, 534-536- Williams, Austria Medical Journal, 1884. Rendu, Retrecissement non-congenitale de I'artere pulmonaire, endarterite vegetante. Union Med., Paris, 1884, 3 s., XXXVII, 257-297. CouPLAND, S., Mycosis cndocardi. Lancet, London, 1885, I, 477. Berti, G., Di una rarissima e forse unica vigiatura congenita del cuore osservata in un bambino che visse 2 mosi. Bull. d. Soc. Med. di Bologna, 1887, 6 s., XX, 145-158; i pi. Meigs, Origin of disease, 1897, p. 56. Anthrax. — Anthrax is a bacillus which has become gener- ally distributed over the world, but it seldom affects man. It has been found in the human heart but a few times. It was discovered by Davaine and Rayer in 1850. Koch discov- ered the spores. It infects by being taken into the body with food, water, or air, or it may do so by coming in contact with the body in many ways. It may be primary or secondary in the heart. The period of incubation is from a few hours to four days. Bacillus (Edematis Maligni. — Bacillus oedematis maligni is a progressive gangrenous oedema and emphysema resembling the bacillus anthracis. The colonies have a granular appearance, forming long chains, which are often twisted. It may be pri- mary or secondary, but is usually secondary. It is one of the few bacilli found in the heart. It attacks all forms of animal life, and all kinds of living tissue. This bacillus is found on all serous surfaces, internal or- gans being but slightly affected. It is often associated with the bacillus of tetanus, and originates in the fecal matter of fowls, garden earth, and filth in general. Tuberculosis (1826-1903). — Tuberculosis may be primary or secondary; more frequently secondary. In the form of 238 THE SURGERY OF THE HEART nodules, miliary abscesses, or ulcers, varying in size; it may invade the endocardium, pericardial surface, or the muscular structures, in part or as a whole. It may occur in child- hood but is more frequent between the fifteenth and thirtieth year, and is, as a rule, slow in its development. It is some- times associated with syphilis. Historical. — Macmichael states that he found tuberculous deposits in the cardiac cavities, pericardium, and lungs. Post records a case of pericarditis with tuberculous nodules in the cardiac substance. Hache mentions tuberculous afifections of the heart. Gilman speaks of a case of extensive tuberculiza- tion in the walls of the heart. Banks mentions a scrofulous tumor in the posterior wall of the left ventricle of the heart. Gros records one of tuberculous cardiac granulations, with complete adherence of the pericardium to the heart. De Costa (i860) records a case of tuberculous disease of the walls of the heart; Sherad ( i860) mentions a similar case. Leyden ( 1869) wrote upon three forms of cardiac tuberculosis : (a) heart, (b) muscle, (c) endocardium clots in cavities. Demme (1887) records a case of primary tuberculosis of the heart; Oliver (1887) gives a case of tuberculosis of the heart and pericardium. Sumbera (1889) mentions a case of cardiac tuberculosis, following acute general miliary tuber- culosis. Labbi (1896) reports two cases of tuberculous myo- carditis, one in a boy six years of age, and the other in a girl of four years. Sabraze ( 1899) reports a case of tuberculous dis- ease at the base of the sigmoid valve and pulmonary artery. Hektoen (1901) reports tuberculous perimyocarditis with a tuberculous aortic aneurysm in a dog. Jones says that tuber- culosis and syphilis are both exciting and predisposing causes of muscular and valvular lesions of the heart. Smith records two cases of tuberculosis of the heart. ANIMAL PARASITES— PARASITIC FUNGI — BACILLI 239 BIBLIOGRAPHY Macmichael, London Med. and Phys. Journal, 1826, I, 119-121. Post, A. C, Pericarditis; tubercles in the heart. New York Med. Jour., 1830-31, I, 253-255. Hache, Rap. de michon. Bull. Soc. Anat. de Paris, 1832, VII, 6-19. Cases, tuberculous, degeneration of the liver and heart. Extensive follicular ulceration of the mucous membrane of the stomach. N. Am. Arch. Med. and Surg. Soc, Baltimore, 1835, II, 169-172. Oilman, C. R., New York Med. Gaz., 1842, II, 385. RosER, Ein fall von herz und pancreas tuberkelen und ein fall von periodischer blut-leckenkrankheit. Med. cor-Bl. d. Wurlemberg, artzl. der Stuttgart, '1843, XIII, 134-142. Lapelletier, Tubercules en dedans et en dehors du pericarde, fausses membranes unissant les deux feuillets de cette poche fibro-s^reuse (also Rap. de Bonnet). Bull. Soc. Anat. Paris, 1847, XXII, 298-302, Gayes, liber tuberculosis cordis. Deut. Klinik, Berlin, 1850, II, 357- Banks, Dublin Quart. K. M. Soc, 1850, X, 206. ToTON, Tubercule du coeur. Bull. Soc. Med., Paris, 1851, XXVI, 221. Betz, F., Das blasen am herzen tuberculoser. Med. Cor-Bl. d. ArztL, Stuttgart, 1854, XXIV, 282-284. Gros, C., Bull. Soc. Anat., Paris, 1859, XXXIV. Von Recklinghausen, F., Tuberkel des myocardium. Arch. f. Path. Anat., Berlin, 1859, XVI, 172. De Costa, J. M., Proc. Path. Soc, Philadelphia, i860, II, 34. Sherad, C. C, Med. and Surg. Reporter, Philadelphia, i860, IV, 132. RoKiTANSKY, MiUiar tuberculose des herzfleisches. Ztsch. D. K. K. Ztsch. d. Aerztle zu Wien, i860, XVI, 771. Wagner, E., Tuberkel des endocardium. Arch. d. Heilk., Leip- sic, 1861, II, 574. 240 THE SURGERY OF THE HEART Haberling, G., De tuberculose, myocardie, Britislaviae, 1865. Barcellai, G., Osservazione di una tuberculosi del cuore. Uni- versity di Med., Milano, CCVIII, 346. Leyden, Deutsch Med. Woch., Jan. 9, 1869. ScHOEFFELER, G. W., Ubcr die tuberkulose des herzfleisches. Tubingen, 1873. Peacock, T. B., Adventitious products in the heart. Syst. Med. (Reynolds), London, 1877, IV, 165-181. Sanger, M., Uber tuberkulose des herzmuskels. Arch. d. Heilk., Leipsic, 1878, XIX, 448-472. Hirschsprung, H., Groser herztuberkel bei einem kinde. Jahrb. f. Kinderh., Leipsic, 1882, XVIII, 283-287. Albert, H., Ein fall von tuberkulose des herzens. Kiel, 1883. Rochet, Tumeur tuberculeuse du coeur, mort subite. Ibid, 1887, Demme, Wien. Med. BL, 1887, X, 1545-47. Oliver, Rep. Proc. Northumb and Durham Med. Soc, New- castle upon Tyne, 1887-88, 107. Weber, C., Ein fall von miliartuberkulose endocardis. Koln, 1889. SuMBRRA, F., Casop. lek. cesk, v. Praze, 1889, XXVIII, 899- 901. Trippier, R., Note sur un fait contribuant k etablir I'existence de I'endocardite tuberculeuse. Arch, de Med. Exper. et d'anat. Path., Paris, 1890, II, 361-386; i pi. Thiry, C., Un cas de tuberculose du myocarde, avec examen his- tologique et bact^riologique. Presse Med., Paris, 1890, II, 374- BiRCH-HiRSCHFELD, F. V., Ubcr tuberculose in herzthromben- Verhandlung d. gesellch. Deutsch Natur }. u. aertz., 1891, Leipsic, 1892, LXIV, pt. 2, 163. Noel, J., Gros tubercule du coeur. Ibid, 1892, LXVII, 403. PoLLAK, S., Uber tuberkulose des herzmuskels. Ztsch. j. Klin. Med., Berlin, 1892, XXI, 185-194. Bret, J., Tuberculose du myocarde. Province Med., Lyon, 1893, VII, 181-184. ANIMAL PARASITES— PARASITIC FUNGI — BACILLI 24I Hanot, v., Contribution k I'etudc de I'endocardite tuberculeuse. Arch. Gen. de Med., Paris, 1893, 1, 727-732. Tessier, p., Rapports du r^trecisscmcnt mitral pur, avec la tuber- culosa; etiologie, pathogenic clinique. Clin. M^d. de la Charity, Lcfons et m^m., Paris, 1894, 913, 1009. Bruggiser, W., Tuberkulosc dcs myocardium. Wurzburg, 1894. Valentin, G., Contribution a I'etude de la tuberculose myocar- dique, Paris, 1894. LoNDE et Petit, Endocardite v^g^tante tuberculeuse. Arch. gen. de Med., Paris, 1894, I, 94-102. KoTLAR, E., Uber herzthrombentuberculose. Prag. Med. Woch., 1894, XIX, 78, 97. Vaquez, H., Du coeur des tuberculeux. Clin. M^d. de la Charity, Lefons et mem., Paris, 1894, 187-194. BiONDi, Beitrag zum studium der encarditischen efflorescent bei tuberculosen. Centrbl. /. Allg. Path. u. Path. Anat., Jena, 1895, VI, 105-107. Labbe, M., Tuberculose du myocarde. Rev. Mens, de mal. de Pen}. Paris, 1896, XIV, 280, 294. Leyden, Uber die affection des herzens mit tuberculose. Deut. Med. Woch., Leipsic und Berlin, 1896, XXII, 1-19. ScAGLiosi, La tuberculosi del cuore. Rijorma Med., Napoli, 1896, XII, pt. 4, 781. Sangalli, G., Fatti straordinari di somma estensione della tuber- culosi nel miocardio dell' uomo. R. ist Lomb. di Sc. e Lett, Rendic, Milano, 1896, XXIX, 678-690. Ramond, F., Hypoplasie cardio-vasculaire chez un tuberculeux. Bull. Soc. Anat., Paris, 1896, LXXI, 151. Barie, E., La tuberculose du coeur. Semaine Med., Paris, 1896, IV, 589-91. Brosch, a., Ein fall von herztubcrculose mit typischen " Weilschen Symptomencomplex " ein causuistischer beitrag zur frage der einheit der aetiologie des von Weil beschriebenen krankheits- bildes. Wien. Med. Presse, 1896, XXXVII, 985-1014. Labbi, Rev. mens, des Mal. de PEnj., June, 1896. 242 THE SURGERY OF THE HEART ToNOTOYNONT, Tuberculosc du myocarde. Bull. Soc. Anat., Paris, 1897, LXXII, 101-103. Perox, a., Tuberculose du myocarde chez rhomme. Bull. Soc. Anat., Paris, 1897, LXXII, 824-826. Nattax-Larrier, Tuberculose du cceur. BiUl. Soc. Anat., Paris, 1897, LCCII, 460-462. Hand, A. Jr., Tuberculosis of the myocardium. Proc. Path. Soc, Philadelphia, 1897-98, n. s., I, 92-96. Kauffmaxx, E., Beitrag zur tuberculose des herzmuskels. Berlin Klin. Woch., 1897, XXIV, 667-671. KuLESH, G. S., On tuberculous thrombi of the heart. Bolnitsch. Gaz. Botkina, St. Petersburg, 1897, VIII, 11 71, 1219. Letulle, Etude microscopique d'un cas de tuberculose du coeur. Bull. Soc. Anat., Paris, 1897, LXXII, 200-202. Mathieu et Xattax-Lerrier, Tuberculose du pericarde et du cceur consecutive a une adenopathie tracheo-bronchitique granulee. Bull, et mem. Soc. Med. d. Jwp., Paris, 1897, XIV, 75^759- FucHS, A., De la tuberculose du myocarde, Paris, 1898. Etiexx*e, G., Endocardite vegetante tricuspidienne tuberculeuse. Soc. de Med. de Nancy, C-r. Mem., 1898-99, p. XXVII. MiCH.\ELis ET Blum, Uber experimentelle erzeugung von endo- carditis tuberculosas. Deut. Med. Woch., 1898, XXIV, 550. Sabraze's, Bull, et Mem. Soc. Med. d. Hop., Paris, 1899, XVI, 805- 809. Aguerre, J. A., Sur un cas d'endocardite a bacilles de Koch, chez une tuberculeuse. Bull, et mem. Soc. Anat., Paris, 1899, LXXIV, 434. Cabaxx^es, C., De la tuberculose chronique des oreillettes. Gaz. Heh. d. Soc. Med. de Bordeaux, 1899, XX, 506-509. MixiCH. K., Diverticulum cordis e tuberculo solitario ortum Orv'osi Hetil. Budapest, 1899, XLIII, 668. HoiSHOLT, A. W., A case of large solitary' tubercles of the heart. Tr. Med. Soc. California, Monterey, 1899, XXIX, 202-208. Imerwol, V. L., Despre ciorsa cardio-tuberculoasa la copii. Bull. Soc. d. Med. et Nat. de J essay, 1899, XIII, 139, 171, 203. ANIMAL PARASITES— PARASITIC FUNGI— BACILLI 243 Imerwol, V. L., tJber die bindegcwebe induration des herzfleisches (myofibrosi cordis). Deut. Med. Woch., 1900, XXVI, 750, 753. MosER, A., Tuberculosis of the heart. Med. and Surg. Rep., Bos- ton City Hospital, 1900, XI, 194-203. Zu Jeddeloh, O., tJbcr knotige tuberkulose des herzcns. Kiel, 1900. EiSENMENGER. V., Zur kcnntniss der tuberkulose des herzmuskels. Ztchr. }. Heilk., Wien und Leipsic, 1900, XXI, 2 Heft, 74-92. Hektoen, L., Medicine, Detroit, 1901, VII, 193-202. Jones, F. A., American Medicine, Vol. I, No. 11, p. 183. Smith, W. M., Medical News, Nov. 8, 1902, p. 885. Bacillus Aerogenes Capsulatus (Gas Bacillus) — This bacillus has been found in the heart muscles of rabbits by Olhmacher, who says that it was not found in the smears of the heart's blood. It was first described by Welsh, who says that it prac- tically dominates the whole field of pneumatopathology. It is extremely virulent but dies at about the end of fourteen days. Bacillus Typhosus. — Typhoid bacilli have recently been found in the heart of man, by Vincent (Merek Medicine, Feb. 17, 1892). They have been found in nearly all organs and tis- sues of the human body. So far as known they are secondary, and the effect of their presence in the heart is but little under- stood. MISCELLANEOUS BIBLIOGRAPHY BiACH, A., tJber die sogenante idiopatische herzhypertrophie. Wien. Men. Woch., 1883, XXXIII, 1429-1461. PippiNGSKOLD, Sudden death caused by paralysis of heart from sclerosis. Finska lak-sllisk Handl., Helsingfors, 1883, XXV, 327- Prioleau, L., Hypertrophic cardiaque avec n^vrite parenchyma- teuse. Jour, de Med., Bordeaux, 1883-84, XIII, 291. UsKOV, N. v.. Pathology of nerves of heart. Med. pribav k. Morsk sborniku, St. Petersburg, 1883, Aug., 38-45. 244 THE SURGERY OF THE HEART Lannois, M., Sur quelques points de la pathologie et de la phys- iologic pathologiques du coeur. Rev. de Med., Paris, 1884, IV, 424-432. Williams, A. D., Cardiac thrombosis. Asylum J., Berbice, 1884, No. 392. Neumann, O. P., Statistischer beitrag zur interstitielen myocar- ditis. Berlin, 1885. Epstein, A., Defects des kammerseptums partieller defect des vorhofseptums einmundung der beiderseitigen lungenvenen in die obere hohlvene und das rechte herz, einmundung eines lebervenenstammes in das linke herze rechtslaufige aorta maugel der nulz und des grossem netzes gemeinschaftliches dunn, und dickdarmgekrose nebst andern abnormitaten. Ztsch }. Heilk., Prag., 1886, VII, 308, 932; i pi. Letulle, Note sur la degenerescence amyloide des cellules muscu- laires du cceur. Bull. Soc. Anat., Paris, 1887, LXII, 352-355. RuMPF, Uber das eanderherz. Verhandlung Cong. Innere Med., 1888, VII. Mann, M., Cortriculare binatrictum eine entwickelungs-geschicht- tiche studie. Beit. z. Path. anat. u. allg. Path., Jena, 1889, VI, 487-508; 2 pi. Knoll, P., tlber incongruenz in der thatigkeit der beiden herz- halften situngsb. k. Oked d. Wissens math-nutura cl. Wien, 1890, XCIX, 31-53; 6diag. Stabler, O., Uber eine seltene missbildung des herzens. Ver- handlg. d. Phys.-Med. Desellsch. zu Wurzburg, 1890-91; nf. XXIV, 61-103; I pi. Unverricht, iJber abwechselnde zusamenzeigung der beiden herzhalften. Systolia alterans. Berlin. Klin. Woch., 1890; XXVII. 58c^5. Heizl, R., August Wittmanns freigelegtes herz, geschichte der op- eration nebst beobachtungen iiber die normalen bewegungcn des herzens Arb. a. d. Wed. Klin. Inst. d. k. Ludwig-Max- milians Univ. z. Munch., 1890, II, 405-420; i pi. Dressard, Persistence du bruit de mitrale fonctionnel. Med. Poitiers, 1890, IV, 31. Plate XXIX. Tpie Cross Rkprksents the End of a Kangaroo Ten- don Which Was Used to Ligate the Left Coronary Artery and Vein. (Experiment on the Heart, No. 3, page 263.) The Cross Ria-Ri'Si^NTS the End of a Silk Ligature About the Anterior Coronary Vessels. (Experiment on the Heart, Xo. 6, page 264.) ANIMAL TARASITES— PARASITIC FUNGI— BACILLI 245 CzAPEK, F., Zur pathologischen anatomic der primarcn hcrz- geschwullste. Prag. Med. Woch., 1891, XV, 448-457. JuRGENS, Zur casuistik der primaren herzgcschwultste. Berlin. Klin. Woch., 1891, XXVIII, 1031-34. MuNDET, N., Rotura de corazen par traumatismo mediate. Gaz. Med. Oslal, Borcel, 1891, XIV, 290. Stoss, tjber herzvcrknocherung Dcuztsch. f. Thicrmcd. Leipsic, 1891; X, 51-66. Lepine AND MoLARD, Sur une espece particuliere de myocardite parenchymateuse (non scle reuse). Arch, de Med. Exper. et d'Anat. Path., Paris, 1891, III, 776-9. Bard and Phillippe, De la myocardite interstitielle chronique. Rev. de Med., Paris, 1891, XI, 345-603. Experimentale bei- trage zur kenntniss der myomalacia cordis. Skandin Arch. /. Physiol., Leipsic, 1892-93, IV, 1-45; i pi. ToDESHi, A., Beitrag zum studium der herz-geschwulste. Prag. Med. Woch., 1893, XVIII, 121-135. LiPPERT, H., tJber amyloidentartung nach recurrirencer endocar- ditis. Arb. a. d. Geb. Path. Anat. Inst, zu Tubing. Brun- schweg, 1894-99; II, 408. FoRLANNi, C, L'insufficienza miocardica. Lavori d. cong. di Med. Int. Roma, 1896, VII, 11 7-1 55. BuGGE, J., Sur la deg^nerescence du muscle cardiaque et son role pathologique. Norsk. Mag. }. laegevidensk, Kristiana, 1897, 4, R-XII, 1027-1041. NocoLLE, Contribution a I'etude des affections du myocarde, des grandes scleroses cardiaques. Egbert, J. H., Carditis interstitialis. Philadelphia Polyclinic, 1897, VI, 34. Le anomalie anthropologiche nei cardio- plosci. Arch. Stal. di Med. Int., Palermo, 1899, II, 155- 156. Fiedler, A., Uber akute interstitielle myokarditis. Festschr. z. Feier d. Stadtkrankenhaus zu Dresden-Friedrichstadt, Dres- den, 1899, pts. 2, 3, 24; 2 pi. Huchard, H., Comment traiter la cardio-sclerose. Rev. Gen. de Clin, et Therap., Paris, 1899, XIII, 802-808. 246 THE SURGERY OF THE HEART HocHHAUS AND Reinecke, Ubcr chronischc degeneration des herzmuskels. Deut. Med. Woch., 1899, XXV, 749-753. Vysin, v., On scleroses of the myocardium. Casop lekcesk v. Praze, 1899; XXXVIII, 773, 793, 813, 838. Rudolph, K., Uber zwei falle von grossen defecten der urhof- sochendewand des herzens. Inaug. dissert, Kiel, 1900, Aug. GENERAL REFERENCE Vel Rean, " Operative Surgery," 1856. Clark, " Disease of the Tongue," 1873. Erichsen's, "Science and Art of Surgery," 1878. Holmes's " System of Surgery," 1881. Gross, " System of Surgery," 1882. West, Trans. Royal Mcd.-Chir. Soc, 1883; (Aspiration of Pericardium 80 times). Hamilton, " Principles and Practice of Surgery," 1886. Smith, Stephen, " Operative Surgery," 1887. Agnew, "Surgery," 1889. Billroth, "Surgical Pathology," 1891. Delafield and Prudden, " Pathological Anatomy and His- tology," 1892. Warren, J. C, " Surgical Pathology," 1895. Ashhurst, " International Encyclopedia of Surgery," 1895. Dennis, " System of Surgery," 1895. Gould's American Year Book of Medicine and Surgery^ 1896-97, 1900. Tillmann's " Principles erf Surgery," 1897. "Anomalies and Curiosities of Medicine," Gould and Pyle, 1897. Stevenson, " Wounds in War," 1897. Wharton and Curtis, 1898. Keen, W. W., " Surgical Complications and Sequelae of Typhoid Fever," 1898. Meigs, "The Origin of Disease," 1899. Esmarch and Holwalzig, 1901, " Surgical Technique." CHAPTER XVIII EXPERIMENTAL RESEARCH ON THE HEART OF THE DOG The experimental work contained in this chapter was done at the laboratories of the University of Cincinnati during July and August, 1901. There were forty-five dogs used in this series of experiments, to determine the effects of different kinds of injuries to the heart, pericardium and diaphragm, and the results of various surgical operations thereon. Many valu- able deductions were made, but it will require further work by surgeons and experimenters to determine many of the possi- bilities in surgery for injuries and diseases of the heart. This work is, therefore, but a small contribution to this most inter- esting subject. The author desires to take this opportunity to thank his assistant. Dr. H. V. Spargur, and student Charles T. Souther, for their valuable assistance in conducting these ex- periments. Original Experimental Surgery (1901-2) Nothing indicates more clearly the lack of confidence in surg-ical intervention in lesions of the heart than that the lat- ter have been treated as anomalies. The best history of the surgery of the heart, accessible to the general reader, is to be found in a work that treats of anomalies and abnormalities. They of themselves show that the heart is more susceptible to in- jury, disease, and surgical operation, than is generally sup- posed. 247 248 THE SURGERY OF THE HEART Simple puncture with a needle was at one time thought to lesult in instant death ; indeed such an idea generally prevails at this time. Infection in animals is more likely than in man, because of the great difficulty in making the former sterile and keeping them so, after they have been operated upon. If experimental physiology and surgery have taught any- thing, it is to reason by analogy from animal to man. Animal experimentation has led the way to more successful surgical work, and it will continue to do so. It not only shows what can be done, but it teaches, by manipulation alone, if nothing more, how it should be done. There are many diseases and many lesions which do not manifest themselves, or cause symptoms which are readily discernible. In other words, the particular lesion is wholly un- suspected until it has advanced far enough to produce func- tional disturbances, which are often serious. Then search is made for the cause. Then again, it is possible to diagnosti- cate certain diseases only by the symptoms caused by the func- tional disturbance, produced by the lesion, and not by the lesion itself. The functional disturbances, resulting from a given lesion, are not always the same. Pathological physiology re- ceives only scant attention, or none at all, in our medical schools, yet it is of the utmost importance. Only a few works on this subject are accessible, and these are unsatisfactory in some respects. Many questions of the utmost importance are unsettled. These remarks apply with peculiar force to the heart. The intimate connection of the function of respiration with the heart, and the disturbance produced in the functions of the other, when either heart or lung is diseased, is the reason for taking up both the normal and pathological physiology of the heart. Aspiration of the pericardium should not be attempted, owing to the dangerous consequences, such as injury to the coronary, internal mammary, and intercostal vessels, and puncture of the walls of the heart itself; and also, the possibili- RESEARCH ON THE HEART OF THE DOG 249 ties of infection from the escape of fluid, through the puncture, into the pleural cavity and mediastinal space. The probabili- ties are, that many cases in which fluid has been purported to have been aspirated from the pericardium, that it was con- tained within the pleural cavity, mediastinal space, pulmonary cyst, or abscess, or a pleural cyst. The heart is very susceptible to alkaline solution, which accelerates it. The absence of stomata in the diaphragm within the pericardium, tends to exclude fluids from the peri- toneal cavity. The pleural fluids will, however, pass through the pericardium. In the lower animals (fish), the pericar- dium and diaphragm are wanting. As they ascend in scale, the pericardium becomes more fully developed to form the pericardial sac ; the same is also true of the diaphragm. There is no way of determining whether or not the heart will absorb to any degree any fluid that may be contained within the pericardium. Nor have such observations been made upon the ability of the pericardium itself to do so. It has, however, been determined that the heart will not with- stand a high degree of pressure, from fluid or otherwise, within the pericardial space. It will stand a greater pressure, if the pressure be gradually increased, as in the case of pericardial ef- fusion, resulting from pericarditis. It will, in a normal state, absorb more or less of its exudate ; and it will probably have a greater capacity to absorb in a pathological state. Pressure, from any source, may be sufficient to force a part, or all, of the blood out of the cavities of the heart. This may be gradual or sudden, fatality resulting only when functional circulation cannot be maintained. The consequences are less severe, and serious trouble is delayed, if the pressure is in- creased slowly, as by the growth of new tissue. Rapid press- ure is usually due to change in shape of the chest, from trauma, or from concealed haemorrhage, within the pericardial, pleural or mediastinal spaces. 250 THE SURGERY OF THE HEART Operative Technics Sterilization of the local area of the dog is almost impos- sible. The area should be shaved after the dog has had a thorough bath, which is difficult to give to tramp dogs, as they are not accustomed to it. A sterile sheet, in w^hich there is a hole large enough to operate through, should cover the dog. Alcohol or turpentine is applied to the shaven surface, which is then ready for incision. Ether should be employed in all cases for operation, and carried to complete relaxation, and then chloroform given to produce death. The incision should be made longitudinally, beginning at the third or fourth rib on the left side, and about one-third to one-half inch from the internal mammary artery, and diverg- ing slightly from the sternum down to the desired point, even to the apex of the heart. It may be extended to the attachment of the diaphragm, and down to the costal cartilages. The ex- ternal soft tissues, being divided, are then reflected outward, great care being taken not to have the point of the knife slip into the chest cavity, as the heart, lungs, or arteries may be injured. Divide the third, fourth, fifth, sixth, and seventh ribs if necessary. Great care must be observed, in opening the chest, that bone spiculse are not left to lacerate the heart during its pulsations ; otherwise serious, if not fatal laceration of its wall might ensue. Such an accident must be guarded against dur- ing the entire operative procedure. Great care must be taken to avoid such an injury to the pericardium also. It is, there- fore, safer, completely to sever the bony structures with a sharp cutting instrument, than to fracture them by force or other- wise. The same precautions should be observed in dealing with the cartilaginous structures. If necessary, the cartilages may be cut near the left border of the sternum and retracted outwards to the right or left. If the mediastinal space be opened, the respiratory motion RESEARCH ON THE HEART OF THE DOG 25 1 of the thin membrane, that walls off the right lung-, may greatly interfere with rapid work. It will especially be so, if over distention of the right lung should rupture it. The right lung would then retract upon itself. It is, therefore, safer and less difificult if that space be not opened. The opening can, however, be closed with the hand of an assistant during the en- tire operation. The bleeding in the skin and muscle is seldom annoying. The intercostal arteries usually cease to bleed after they have been exposed to the air, and sponge pressure; if not, they can be easily controlled by forceps. The internal mammary once wounded, the haemorrhage is great, and troublesome to check, except in one way, namely, by pulling the skin to the right, leaving only the costal cartilage and muscles to constitute the chest wall, then with the finger, or a larger pair of acupressure or artery forceps, including all the tissues between the carti- lages, just above the wound, in the forceps, which is put on parallel to the long axis of the costal cartilage, or in the trans- verse diameter of the chest. It may be necessary to do this above and below the wound, as the internal mammary artery may bleed a little from below, the anastomosis being very free with the deep epigastric. After the haemorrhage has been checked, it is best to apply a ligature en masse, as it saves time, which is an item with the heart exposed. The first opening should give good view and room to work; if not, incise two inches to the left in the intercostal space, and cut the ribs transversely with a pair of sharp bone forceps, beginning at the outer border of the incision, in the intercostal space. If necessary, other ribs are divided, that a flap sufficiently large may be turned back to give ample room. There is no occasion for using gauze, or any kind of pack- ing in heart injuries, especially in pericardial injuries, as bleed- ing from the pericardium is insignificant except in cases of injury at the point of attachment of the extreme base of the heart; even then experiments show that haemorrhage from in- 252 THE SURGERY OF THE HEART juries to it is but slight. To secure beneficial results from gauze packing in heart injuries, it is necessary to employ firm pressure. To do this would interfere with the heart's action. Therefore, it would be more injurious than beneficial because such pressure would force the heart back upon the posterior wall of the thorax. If a patient survives the immediate thrust of a stiletto-like instrument, however small, the probabilities are that the haem- orrhage will be less when the weapon is withdrawn at the end of several hours, than on its immediate withdrawal. The styptic effect of the metal as the result of its coming in contact with blood, together with the formation of clots and the closing of the opening resulting from the puncture, by al- lowing the weapon to remain, will be amply sufficient in a few cases to prevent a fatal haemorrhage on its withdrawal. The blood that most resembles in constitution the blood contained in the cavities of the heart, is that found in the cor- onary arteries, which, like that in the heart, coagulates with wonderful rapidity. The blood, after having made the round in the body, comes back to the heart practically exhausted of oxygen. It not only contains CO2 but other chemical compounds, formed by the debris collected uniting with the constituents of the blood. At the same time it contains more fibrin, and doubtless, also, more of the other elements which add to the coagulability of the blood, for in its course it has taken up the material prepared by the digestion process to repair the wear and tear of the body. In all cases where important blood-vessels were punctured, the observers have been impressed by the rapidity of coagula- tion. It is very probable that nature has so arranged, that in case of trauma, where there is haemorrhage of the more impor- tant organs, coagulation shall be more rapid than elsewhere, thus preventing death. It seems probable that the rapidity of coagulation is proportionate to the importance of the organ to the animal economy. RESEARCH ON THE HEART OF THE DOG 253 Contraction of a lung, when the thorax is opened, will cause congestion of the heart. The contraction of the lungs, whenever the chest is opened, exerts considerable pressure upon the various pulmonary blood-vessels and thus forces a volume of blood, equal to nearly the entire volume of blood normally contained in the lung, into the already engorged heart, thus bringing about a congested condition of this organ. Care should be taken in operations upon the heart, lest un- due manipulation cause death from paralysis of the vagi. Having checked all haemorrhage from the chest-wall incis- ion, and the wound being dry, lift up the pericardium with a tenaculum. Great care must be taken not to puncture the car- diac tissue, or coronary artery. The tenaculum should be in- serted over the ventricles, as there is danger of wounding the thinner auricular wall. The incision should be made in its longitudinal diameter. This incision in the pericardium may be extended to any de- gree necessary to familitate rapid work, and should be done by tearing. Each bleeding vessel must be closed as soon as opened. When the pericardium is incised, it retracts, and owing to its thinness, is almost lost sight of. It however can be replaced, and sutured in position with a moderate degree of ease. The pericardium normally is closely filled by the heart, and when the heart is beating, and not even restrained by the chest wall, its range of movement is very great. This must be seen to be appreciated. The pericardial cavity is now cleared of all clots, by one sweep of the finger if possible. Gauze may be carefully wrapped around the finger, but it is best not to use it. The heart is gently grasped in the palm of the left hand, great care being taken not to use any more pressure than is absolutely necessary to enable the needle to be plunged through the wall of the incision. The heart can be handled to a remarkable degree without any appreciable change in beat, except the dilatation caused by 254 THE SURGERY OF THE HEART the loss of the supporting sac — the pericardium. This hand- hng of the heart is safe, provided not too greatly prolonged. The loss of support of the chest wall and, more important, of the closely fitting pericardium cause a great extra strain on the myocardium. Careful inspection of the naked heart shows its great dis- tention, and when it seems, or really is, paralyzed by overdis- tention, holding together for a moment the wound in the chest wall will cause the heart to regain its normal action. The operation may now be continued. If necessary, this may be repeated several times during the operation. The operation being finished, the heart is returned to the pericardial cavity, the pericardium now being brought into position with small tenacula and a running suture of catgut placed in it. As the artery tension is not great when the chest wall is closed, a suture can be used that need not last so long. The pericardium tends to go back in place after the replacement of the heart. There was a plastic pericarditis in all the autopsies, and the pericardium was adherent for a distance around the incision in the pericardium of from one-half to one inch. In most cases the pericardium was not sutured, and the re- sult was very good as to replacement. So good, that in any case in which there is danger in prolonging the operation, one is justified in allowing the pericardium to remain open, for the closing of the wound tends to keep the heart in place, and keep the pericardium closed. This same work does not control so well the haemorrhage in wounds of the left ventricle, as the wall is very strong and resilient ; however, this method is the best and most convenient, and it is always easy to govern the degree of pressure, which should be only great enough to prevent blood from coming out (luring systole. In diastole, the pressure should be slightly relaxed. As to putting the needle through, during systole or diastole, I think that will be forgotten when it comes to the work, as Plate XXX. ,41* ^• ^4 1 Experiment on the Heart, No. 9, page 266. Experiment on the Heart, No. 10, page 266. - Showing Silk Sutures in Place. RESEARCH ON THE HEART OF THE DOG 255 with a heart bounding and changing position at least one-half to one inch, seventy to one hundred times a minute, we are glad to get a needle within one-quarter inch of the work aimed at. \\^hen the auricle is opened, naturally the blood comes out with considerable force, but this can be entirely controlled by putting the ball of the finger over the opening, yet the force does not have to be great enough to obliterate the auricle, or press the walls in contact. The pressure can be accurately gauged in this way, and it controls the haemorrhage almost per- fectly. Suturing the heart is very essential, and should a needle not be ready, the finger can be kept in place while a well-curved needle is passed from one side to the other, under the finger. The needle should be long and semicircular, but not hea\y. Theoretically, to insert the needle in diastole is right, but it is one part of theory that we lose sight of, in the critical moment, and should the heart cease to beat for a few seconds to a min- ute, or even two minutes, as it does, our duty is to keep the fin- ger on the heart wound, and close the wound in the chest by grabbing its edges, keeping finger in position. Then, if the heart resumes its beat, further effort can be made to close : if not, the work is done as best it can be. The question whether to continue work even though the heart stops, is an open one. On one side, we have the ver}- great advantage of a quiet tissue to work on. which will be posi- tively frightening when it comes so suddenly, and on the other, the less chance or probable less chance of resuscitation, if we keep the chest open. We should choose the lesser evil, if we can sometimes decide which really is better. In suturing the heart's tissues, the organ should be held as securely as is consistent with minimum pressure, and the sutur- ing done as rapidly as possible, the knots being made by an assistant. Glover's continuous suture is preferable to all others, because 256 THE SURGERY OF THE HEART fewer and less complicated knots are required. This is espe- cially desirable when silk is used, the object being to get rid of knots by absorption, as quickly as possible. The simple continuous suture without knotting, except in the first and last punctures, would be ideal, but for the great danger of the suture breaking, and thus allowing reopening of the wound. This is the great danger in using absorbable or non-absorbable material, as it must, of necessity, be very light. Both silk and kangaroo tendon have been used with great satis- faction in suturing penetrating and non-penetrating wounds of the heart, also for ligating the coronary arteries at various points. However, the preponderance of evidence is in favor of the interrupted suture, and that it should be twisted silk, even though kangaroo tendon is more absorbable. Wounds of the heart repair themselves, as rapidly as, if not more so than those of other tissues, and the pericardial adhesions are proportionate to the extent of injury, whether clean or infected. Interrupted sutures therefore should be used, and the needle and silk should be as small as will render service. They should be about one-eighth of an inch apart, and taken deeply in the tissue. If the cavity of the heart has been opened, the needle should be made to pass through the entire thickness of the heart's wall. If the endocardium has not been punctured, the needle should be made to traverse the floor of the incision. The strength of the suture material should be determined at time of operation. Knotting of the sutures should be firm, and their respective ends about one-quarter of an inch in length. If shorter, the constant action of the heart may possibly untie them. Kangaroo tendon has been used in suturing muscular tissue of the heart, and in ligating the coronary arteries, with consid- erable satisfaction, more especially in the latter. Its life will depend upon the size and quality — the greatest objection being to its size. A larger needle is required and the punctures from RESEARCH ON THE HEART OF THE DOG 257 it must necessarily be larger than when silk is employed. Cat- gut offers the same objections. It is pretty well agreed upon by experimenters that the sutures should be applied during systolic relaxation, that the cut edges may be perfectly coaptated. However, Rhen tied them during diastole with equal success. It is not necessary to suture or apply any kind of treatment to some wounds of the heart, as they will close and recover spon- taneously. It is impossible to say, or determine, the size of wounds necessary to be sutured or to be let alone, except when there is continuous bleeding, which can only be determined by opening the chest. It must necessarily require much time, and careful observation of many heart wounds, to determine the necessary procedure in each individual case. The probabilities are that punctures, however small, into the left ventricle or auricle, become enlarged with its systole, and that death results sooner or later from haemorrhage alone. Not so, however, with the right ventricle and auricle, the mortality being less with similar wounds. Therefore, one is justified in believing that sutures are less likely to tear out in the thick walls overlying the cavities of the left heart. This statement appears inconsistent. In the more highly developed and older animals of mature ages, the heart will be more likely to be sutured successfully. The superficial vessels (coronary arteries and veins) lie side by side, and the amount of haemorrhage, in case of trauma, de- pends upon its distance from the origin of those vessels. It will depend also upon the character of the wound. Knife and needle wounds, or those of sharp-edged weapons, bleed the most, and superficial, lacerative, the least. The closure of the chest of animals is difficult, for the reason that the animal cannot be kept quiet. Of course there are sev- ered ribs, and at times these have to be closed in two places. Silk-worm gut and silk (heavy) were used in most cases, silk for the bony wall, and intercostal muscles, one suture 258 THE SURGERY OF THE HEART on each side, or rather one between each rib, the ribs being as nearly approximated as possible. Then the muscle, and the skin, all in one layer, were sutured with silk-worm gut. As before stated, the two tiers of sutures did not come directly above each other, from the fact that after the first incision was made, the outer flap was dissected up for a distance of an inch, and then the wall opened. This puts the two rows one inch apart, and protects them from contamination by infection, and also makes a sort of valve, as in the operations for colotomy and gastrotomy. In putting in the external sutures, they should be close, and extend down into the intercostal muscle under the line of skin incision, to add to the security of the wound. Not often was there any trouble in getting the wound closed well enough to prevent the passage of air into the pleural cavity. Drainage should be provided for in the same way as for wounds in other parts of the body, and governed by the same principles. The dressings should be aseptic, and securely held in place with adhesive plaster, and bandages encircling the body, and about the shoulders. The post-operative treatment requires that simple, nutritious food should be prescribed, with more or less stimulation, as the case may require. Alcohol may be given by the stomacli, in the absence of nausea. If there be nausea, it should be given by the rectum. Artificial heat should be applied, if the tempera- ture becomes subnormal, or if it be otherwise indicated. Oxy- gen is indicated, and is probably the most satisfactory way of stimulating, when stimulation is demanded. Remarks on the Various Experiments In carrying on the series of experiments the object was to induce as many complications as possible. That this might be accomplished, aseptic principles were disregarded, and the RESEARCH ON THE HEART OF THE DOG 259 pleural cavity many times entered. In a few instances, clots were allowed to remain in the pleural or cardial sac, and some- times both, that their disposition might be observed. In Case No. I, two tablespoon fuls of blood were allowed to es- cape from the coronary artery into the pericardial sac, and there allowed to remain. The clot was afterwards found intact. Removal of the pericardium by incision was done in two cases. In one death did not ensue ; dissolution occurred in the other (No. 8) as the result of infection which might have been avoided. In the case of recovery, the heart was adherent to the surrounding tissues. In two cases, the pericardium was di- vided from apex to base, with scissors, and allowed to retract upon itself, leaving the heart practically in the same condition as if the pericardium had been removed by excision. Death resulted in one of the cases. In Case No. 5, the pericardium was divided longitudinally, and sutured to the chest wall with silk. The animal was killed sixteen days afterward. Even though this dog on the third or fourth day removed the sutures in the chest wall with his teeth, the wound was not infected. He was allowed to lick the wound until the sixteenth day, when he was killed. Autopsy revealed about one ounce of serous fluid in the pleural cavity. There were adhesions of the pleura, pericardium, lungs, and heart to one another, and to the chest wall. It has been found that the ligation of either of the coronary arteries at any point of their distribution will not produce death. In Cases Nos. i and 9, silk was used for ligature. In Case No. 3, kangaroo tendon was employed, the ligature being ap- plied at the origin of the artery. The dog's life was taken in the latter case, on the fourteenth day, and complete repair fol- lowing the ligation was found to have taken place. Several similar experiments were made with the anterior coronary arteries, with practically the same results. Accidental puncture of one or more branches of the coronary 26o THE SURGERY OF THE HEART arteries occurred in three cases, more or less complicating the operation. In Case No. 2 the posterior coronary artery was ligated about midway between apex and base; the second branch, being accidentally punctured with the needle, was also ligated at the bifurcation of the main branches. Penetrating and non-penetrating wounds of the heart were made with a bistoury after the chest had been opened, and were allowed to remain open from one to ten minutes, before closing them with suture. In Case No. 6 two incisions were made in the apex, over the left ventricle, each being one-half inch long. The dog died at the end of seventy-two hours. The incisions were estimated to penetrate about one-fourth the thickness of the ventricular wall. They were shown at autopsy to have practically repaired themselves. The dog was found to have general tuberculosis, which was suspected at the time of operation, and which was, no doubt, the cause of his death, there being no other perceptible cause. In Case No. 9, while suturing a penetrating wound, three- eighths of an inch long, made in the left ventricle, the left branch of the anterior coronary artery, which had been acci- dentally punctured, was included in the last and upper suture. The animal died at the end of seventy-two hours. Autopsy re- vealed about a pint of bloody fluid in the pleural cavity, also ad- hesions between the pericardium and chest wall, and between the pericardium and heart. The wound in the heart was com- pletely and permanently closed. In Case No. 10 a fine needle, armed with silk, was made to pass so as to make four sutures closely approximated over the left ventricle, the object being not to perforate the endocardium. Case No. 1 1 demonstrates the suturing of a non-penetrating wound one inch long, involving about half the thickness of the ventricular wall, and in which silk was used for suture. Com- plete suspension of respiration lasted two minutes, but operation RESEARCH ON THE HEART OF THE DOG 261 was not discontinued during this time. Normal respiration was re-established spontaneously. Death occurred seventy-two hours afterward as the result of infection due to the animal hav- ing torn out all the sutures in the chest wall. The incision in the heart had firmly united, the heart itself being nearly firm. In a small non-penetrating wound in Case No. 14 in the wall of the left ventricle a continuous suture of silk was applied. Respiration ceased, as the pericardium was being opened, but soon re-established itself and again ceased upon completion of the last stitch. It was not again re-established. The heart con- tinued to beat two minutes after the last respiration. If death had resulted from the puncture of one or more cardiac ganglia, the heart would not have continued to beat for two minutes after the last respiration. In Case No. 17 death occurred while incision was being made in the left ventricular wall. This may have been due to injury to one or more of the automatic ganglia. This is hardly probable ; at least it has not been proven, because death has oc- curred under similar circumstances without any injury to the heart. An incision requiring two silk sutures was made in the wall of the left ventricle in Case No. 18. These sutures were made too tight, and therefore cut through the muscular tissues of the heart, resulting in death. Needle punctures of the heart were made in several cases, in various portions of the organ. In one, eighteen such punctures were made in the various portions (of the heart) from apex to base, the object being to injure the cardiac ganglia. In no in- stance did death ensue, nor were the movements of the heart influenced to any noticeable degree. Stimulation of the heart to action after it had ceased to beat, was accomplished several times by rhythmically compress- ing the apex of the heart with the fingers, also by pricking the apex of the heart with a needle. The most interesting of all the experiments was in Case No. 262 THE SURGERY OF THE HEART 1 6, in which a non-penetrating incision was made in the left ex- ternal ventricular wall, necessitating the introduction of four silk sutures to close it. Record of Experiments No. I. August 6, 1901, 9.45 A. M. — Incision made in the chest wall, beginning in sixth intercostal space; five ribs resected, pericardium divided, and the left coronary artery ligated, after being punctured. Two tablespoonfuls of blood allowed to escape from the artery, and let into the pericardial space, and permitted to remain there. Silk used for a ligature. Chest walls closed with sutures of heavy silk, and in- teguments sutured with silk-worm gut. At i P. M., dog was in good condition, drank water, and walked about. Autopsy. Dog died some time during the night of August 6. He was injected on the following day with formalin. Post mortem made August 9 at 2.30 p. M. General peritonitis, peritonaeum greatly con- gested, abdominal cavity filled with a bloody serous effusion; left upper lobes of left lung congested; pericardium adherent to both chest wall and heart. No. 2. August 6, 1901, 10.20 A. M. — Time of operation 6 minutes. Mixed fox-terrier, weight 25 pounds, age two years. Apex beat nor- mal; pulse no. Incision made two inches to the left of the median line, extending from second to eighth rib. Pericardium divided from apex to base. In passing a small needle about the posterior coronary artery midway from apex to base, the second branch was accidentally punctured. Bleed- ing was profuse, requiring Hgation. The ligature was applied at the bifurcation of the main branches. About four ounces of blood escaped before the ligature could be secured. Clots were taken out of the peri- cardial cavity three different times. Respiration ceased at the end of eight minutes. Heart, however, continued beating sixteen minutes. Resorted to tracheotomy, ten minutes after cessation of respiration; and various artificial methods were of no avail. Before this, the oper- ator had to stop occasionally and hold chest opening closed with his finger, as respiration was not good at any time. Autopsy was made immediately. No special cause of death dis- Plate XXXI. Experiment on the Heart, Xo. ii, page 266. Je> r ^f * ^ Experiment on the Heart. Xo. 12. page 267. Showing Silk Sutures ix Pl.\ce. RESEARCH ON THE HEART OF THE DOG 263 coverable. It was probably due to paralysis of vagi, the result of manip- ulation of the thoracic organs during operation. No. 3. August 6, 1901, 2.45 p. M. — Time of operation eight min- utes. Mixed spaniel, weight 25 pounds, age one and one-half years, well nourished. Incision made two inches to left of median line, from second to eighth rib, cutting through the cartilages. A transverse incision also made at the lower end of seventh rib. Left coronary artery ligated at base with kangaroo tendon. About one and one-half ounces of blood escaped from the internal mammary and intercostal arteries. This blood flowed into the pleural cavity, because the pericardium had been divided. The pericardium was not sutured. Blood permitted to re- main in pleural cavity, where it soon clotted. (Plate XXIX.) Autopsy, August 20, 1901, 9 a. m. — Heart, lungs, and sternum removed intact. Heart adherent to the line of incision in the chest wall. Lobes of left lung adherent to both heart and chest wall. No. 4. August 6, 1901, 4 p. M. — Mixed bull, weight 20 pounds, age one and one-half years, general condition at time of operation, good. Chest wall incised two inches to the left of median line, from second to seventh rib. Pericardium divided from apex to base. A puncture one-eighth inch wide made with a bistoury in the wall of the heart, over lower end of the left ventricle. Immediately on withdrawal of the knife> blood spurted out with great force. The force was so great that the blood was thrown a distance of twenty feet. This prevented further operative procedure. Heart ceased beating at the end of four minutes. Autopsy was made at once. Examination of the heart showed that the forcible expulsion of blood enlarged puncture in the wall by the bistoury, also shght lacerations to the right of the puncture, made by the forceps in an attempt to control the haemorrhage. All organs were found to be normal. No. 5. August 15, 1901, 1.30 p. M. — A young street dog, half pointer (liver colored), healthy, but emaciated, weight 25 pounds, age nine months, took ancesthetic very hard. Incised fourth, fifth, and sixth ribs. Pericardium divided and sutured to chest wall with silk, and silk-worm gut used to close chest wall. Autopsy, August 31, 1901, 9 a. m. External sutures had either broken or were gnawed, on the third or fourth day following operation, 264 THE SURGERY OF THE HEART At the autopsy, external wound, though open, was clean and without infection, although in the case of all the other dogs, where the external sutures gave way, death occurred in a few days from infection. The incision dividing the ribs, etc., had healed so perfectly that it was with the utmost difficulty that the line of union could be discovered. About one ounce of serous fluid in pleural cavity ; but all thoracic organs were in a good condition. There had probably been a great amount of the fluid absorbed. The fluid found would have been absorbed in a few days. Adhesion of the pleura, pericardium, lungs, and heart to one another and to the chest wall. No. 6. August 17, 1901, 10 A. M. — A brown spaniel bitch, about one year old, weight 20 pounds. She was tuberculous. Four ribs incised. A slit one and one-half inches long made in pericardium. The wall of the heart slightly scarred at the base over left ventricle. Pericardium was not sutured. Chest wall closed with sutures of heavy silk. Integuments sutured, partly with silk-worm gut, and partly with silk, because the operator ran short of silk-worm gut. Autopsy. Dog died August 20, 1901, at 10 a. m. Post mortem was made at once. Dog was found to have been in an advanced state of pulmonary tuberculosis. Death due to infection. Pus about peri- cardium. (Plate XXIX.) No. 7. August 20, 1901, 8.30 A. M. — Water spaniel, about two years old, weighing about 25 pounds. Operator, in making the incision through the chest wall, began too near the median line, and thus accidentally severed the internal mam- mary artery. Further operative procedure had to be suspended, in order to secure this artery. A silk ligature was applied transversely in the intercostal space, next above the one where the cut in the artery was made. (This accident served as a caution to those present. In all operations involving the incision of the chest wall, it is safer to cut too near the spine, than too near the sternum. In other words, make the incision as far from the sternum as possible.) Respiration ceased at this point. The suspension lasted over two minutes. Tongue was cyanotic, heart beat in time and energy reduced 50 per cent. No attempt was made at artificial respiration. The only thing done was to hold the chest oi)cning shut with the fingers. Respira- tion finally became normal, and operation continued. The pericardium was incised one and one-fourth inches over and below the origin of left RESEARCH ON THE HEART OF THE DOG 265 coronary artery. One branch of this artery was accidentally punctured with a tenaculum, in lifting up the pericardium, causing profuse haemor- rhage. Condition of dog precluded further operative measures. A clot was allowed to form in order to stop the bleeding. Two or three drams of blood, which entered the pleural cavity, were allowed to remain. Chest wall sutured with silk, and integuments closed with sutures of silk-worm gut. Autopsy. Dog died suddenly at 12.15 P- ^-y August 21. He had been walking around during the morning, but was not in very good con- dition. He had been lying down, got up, staggered five or six feet, and fell dead. Post mortem held immediately. One-half pint of fluid in left pleural cavity. No clots in the pericardial space. Pleural cavity was tilled with clots of blood, as was also the heart. A fibrous clot closed the incision in the pericardium, thus hermetically sealing it. Ligature about left coronary artery intact and covered by fibrous exudate. Left lung greatly congested, but not pneumonitic. Lobes of left lung adher- ent to the pericardium. Slight adhesive exudations connected heart and lungs with the anterior thoracic wall. Clot, forming the adhesion to the pericardium, was accidentally removed at the autopsy. The right margin of the incision in the pericardium was inverted. Evidences of infective pleurisy. The blood permitted to remain in the pericardial and pleural cavity had been partly absorbed. The effusions present were no doubt pleuritic. Death, perhaps, due to infection. No. 8. August 20, 1901, 10 A. M. — Terrier (Scotch), weight 20 pounds, age one year. Incised chest wall, two inches to the left of the median line. Re- moved pericardium by a circular incision. Respiration ceased at this point, remained suspended ninety seconds. There was no bleeding from the pericardium. Autopsy. Dog died some time during the night of August 22 (death probably occurred about 12 o'clock, August 21-22). Post mortem II A. M., August 22. About eight ounces of fluid in left pleural cavity, evidently from the pericardium. The fluid was covered by more or less blood, but was not purulent. A tough fibrous exudate covered the exposed surface of the heart (that portion devoid of pericardium). Ad- hesions connected the left lung to the chest wall, and the heart to the remnant of pericardium. Left lung partially collapsed, and superior lobe congested. 266 THE SURGERY OF THE HEART No. 9. August 20, 1901, 10 A. M. — White dog, weight 25 pounds, age two years. A longitudinal incision was made in the pericardium, which was then sutured through the chest wall. A very fine needle, armed with silk, was used in making three punctures through the walls of the heart, into the left ventricle. On the withdrawal of the needle after the last, an upper puncture, the coronary artery was accidentally punctured. The sutures were made taut. The left branch of the anterior coronary artery was included in the last and upper suture. Sutures were made with both silk and silk-worm gut. Autopsy. Dog died 6.30 A. M., August 22. Post mortem at 10 A. M., August 23. Death due to general infection. A pint of bloody fluid in pleural cavity. Adhesions between the pericardium and chest wall, and between the pericardium and heart. Adhesions, formed of fibrous bands, connected the lungs also with both chest wall and pericardium. The adhesions of pericardium were exceedingly intimate. Stitch abscesses in both rows of sutures, i.e., those closing chest wall and those closing the integuments. Greenish pus filled each stitch hole. Heart, lungs, pleura, and pericardium covered with muco purulent exudate. Even the diaphragm was covered with a similar exudation. (Plate XXX.) No. 10. August 20, 1901, 2 P.M. — Shepherd dog, weight 25 pounds, age two years. Pericardium incised; heart punctured with a fine needle, armed with fine silk. Four sutures were then placed in the external surface of the heart, over the left ventricle. Chest wall closed with silk, integu- ments with silk-worm gut. (Plate XXX.) Autopsy. Dog died 6.30 A. m., August 24. Post mortem 2 p. m. same day. Death from infection. Fluid in pleural cavity. Effusion of blood into the contiguous cutaneous structures. Adhesions con- nected pericardium to the pleura and both to the chest wall. No. II. August 20, 1901, 2.30 p. M. — Shepherd dog, female, weight 50 to 60 pounds, age two to three years. Pericardium incised about one inch. The heart itself was incised over the left ventricle. Cut about one and one-half inches long through the wall (non-y)enetrating). Closed incision in the heart's wall with sutures (interrupted) of silk. Chest wall sutured with silk, and the integuments with silk-worm gut. Respiration ceased, but operation RESEARCH ON THE HEART OF THE DOG 267 was not suspended. Suspension of respiration lasted fully two minutes, then normal respiration was restored spontaneously. Autopsy. Death occurred 8 A. M., August 23. Post mortem 2 p. m., same day. Sutures in chest wall had been torn loose. Infiltration of blood into the contiguous cutaneous structures, two ounces, at the very least, in a clotted condition. External sutures had rotted away. Incision through the integu- ments filled with a foul, ill-smelling, greenish-colored pus. Pleural cavity held about a quart of dark red fluid. Part of pericardium had sloughed away; the remainder was closely adherent to the heart and covered with a mucopurulent exudate. Adhesions connected heart, pericardium, pleura, and lungs to one another, and to the chest walls. Incision in the wall of the heart closely and firmly approximated, and union nearly accomplished. Infection of contents of the thoracic cavity, general. The material forming the adhesion, on visual inspection appeared to be formed of fibrous tissue, held together by half-formed connective tissue. The parietal pleura, where immediately attached to the chest wall, was very much thickened by a mucopurulent deposit on its surfaces, but more especially by an infiltration that presented the appearance of clotted blood. All the thoracic vessels, except the bronchial, were extraordinarily hard and firm when removed from the chest cavity. They felt as if they had been hardened in alcohol three or four days. (Plate XXXI.) No. 12. August 20, 1901, 3 P. M. — A black cur dog, about six months old, weight, 15 pounds. Dog was tuberculous. Chest wall opened and pericardium divided. At this stage of the operation the coronary artery was accidentally punc- tured. Operation suspended to secure the bleeding vessel. Both the cor- onary artery and the coronary vein were included in the ligature applied. The dog's condition being so critical, nothing more was done. Chest wall closed with silk sutures and the integuments with silk-worm gut. Autopsy. Dog died August 24, 1901, 6.30 a. m. Post mortem 2 p. M., same date. General infection. A bloody, serous fluid in the pleural and pericardial spaces. The adjacent cutaneous structures infiltrated with an exudate resembling clotted blood. Adhesions con- nected pericardium to the heart and pleura, and the latter to the chest wall. These adhesions consisted of white, tough, fibrous bands. The incision was filled with foul, greenish pus. (Plate XXXI.) 268 THE SURGERY OF THE HEART No. 13. August 20, iqoi, 3.15 p. m.— A young fox-terrier, age one year, weight 12 pounds. Chest cavity opened and left lung excised. Chest closed with silk sutures; integuments closed with silk- worm gut. Lung stump sutured with gut. Autopsy, August 29, 1901, 2.30 p. m. Dog killed with chloroform, recovery had been rapid and uneventful, and dog had been up and around, manifesting a lively interest in the work in the laboratory. Evidently he had been a pet, for he was very affectionate, and solicited caresses from the operator at each visit to the laboratory. When chest cavity was opened all the organs were found to be in good condition. Evidences of recent congestion of the lungs, adhesions to chest wall. A httle fluid in the pleural cavity, but there were no signs of infection; a few days, probably, would have seen the disappearance of the last vestige of fluid by absorption. There had been also some infiltration of the cutaneous structures, but at time of autopsy it had been about all ab- sorbed. No. 14. August 21, 1901, 10 A. M. — A cur dog, about half pug, weight 18 pounds, age two years. Chest cavity opened, and pericardium divided. An incision, about one-tenth inch in depth, made in the wall of the left ventricle. This incision was closed with a continuous suture of silk. Respiration ceased as the pericardium was being divided, but it began again just as the last stitch was being placed; the dog died. Death was probably due to chest cavity being kept open too long, or to one of the special ganglia in the walls of the heart being pierced by the needle in making the puncture for the last stitch. The operator punctured the heart's wall deeper than he intended. Heart continued beating fully two minutes after respiration had ceased. No. 15. August 21, 1901, 10 A. M. — Cur puppy, three months old, weight 8 pounds. Anaesthetized and throat cut. The puppy was not old enough for this series of experiments, and in order to compare a puppy's heart and lungs with the adult organs, was thus sacrificed. The thorax saved for examination and comparison. Observations were made of his appendix. This was very large, much larger than those of adult dogs weighing fifty or sixty pounds. There was nothing abnormal in this. It but illustrated the law that among the higher orders of the carnivorous RESEARCH ON THE HEART OF THE DOG 269 quadrupeds and also of the still higher classes, the appendix at an early stage of existence is much larger relatively than in the adult. Among some animals this condition is found in the foetus, in others, a short time after birth. It is not only relatively, but even absolutely much larger in early life, in some classes, than in adult life. This law holds good for men, too. No. 16. August 21, 1901, 2 p. M. — A very fat, black mongrel, age four years. Weight, 50 pounds. Chest cavity opened and pericardium divided. An incision one- half inch long was made in the external wall of the left ventricle. In- cision in heart's wall closed with four sutures of silk. At this stage of the operation respiration ceased. Muzzle was taken off (cone for ap- plying the anaesthetic had been withdrawn about the time the operator began to suture). The operator held the opening in the chest cavity closed with both hands. An assistant kneaded the abdomen, in an effort to restore respiration. At the end of the first minute the operator introduced one hand into the thoracic cavity, still holding chest opening closed with the other hand, and stimulated the heart by pinching the apex. After a time the dog took a deep, labored inspiration. Then respiration was suspended again, again a few deep labored inspirations, then suspension for a considerable interval. This procedure continued for several minutes. There would be several deep labored inspirations at comparatively short intervals of time, then inspirations would be single, with a longer interval of time after each respiration, then a series of labored respirations at shorter intervals of time after each inspiration. This alternation of single, deep-labored inspiration at considerable intervals, followed by a series of several inspirations not quite so labored, and at shorter intervals after each inspiration, continued until the dog regained normal respiration. The operator, in stimulating the dog's heart, observed, and called the attention of his assistants to it also, that the heart began beating at the end of each inspiration. There were three beats of the heart after each inspiration. The movements of the heart ceased with the suspension of respiration. After each labored inspiration the heart would beat three times, but would be absolutely motionless in the interval between inspirations. The heart's movements were completely suspended three and one-quarter minutes. Respiration was suspended this length of time, and the heart did not beat until after the first inspiration. It took about three 2^0 THE SURGERY OF THE HEART minutes after the first deep-labored inspiration for the dog to regain normal inspiration. In no case when suspension of respiration occurred in this series of experiments were drugs given subcutaneously or other- wise to promote the heart's action. Neither was resort made to trans- fusion, nor any other artificial means employed to stimulate the heart. Autopsy. Dog died 12 m., August 24, 1901, and post mortem made the same date at 2 p. M. Infection general. A quart of bloody fluid in the pleural cavity. Sutures in both the chest wall and cutaneous structures had rotted away. Pericardium, heart, pleura, and lung were adherent one to the other, and to the chest wall. (Plate XXXII.) No. 17. August 21, 1901, 2.25 p. M. — A brown spaniel bitch, two years old, weighing 30 pounds. Chest cavity opened and pericardium divided. The external wall of the left ventricle was incised. After a vain effort to restore the dog, respiration, which had ceased just after incision, was made. The thoracic and abdominal organs were examined to discover if any lesion of any organ would account for death. No lesions of any character were discovered in any organ. Death is supj^osed to have been due to injury to one or more of the automatic ganglia from the penetration by the knife in making incision. No. 18. August 21, 1901, 2.40 p. M. — A black mongrel bitch, age two years, weight, 35 pounds. Chest opened and pericardium divided and incision made in the wall of the left ventricle. This incision was closed by two sutures of silk. An assistant, in making the first puncture with the needle to suture the chest wall, made too deep a thrust, and injured the coronary artery. Artificial respiration was of no avail. The intention was to complete the operation if respiration could be restored. Autopsy made at 2.50 p. m. proved that the accident was a benefit rather than a loss, as it permitted several valuable observations to be made. The heart continued to beat four minutes after removal from the thoracic cavity. It was discovered that the suture closing incision in the heart's wall had been drawn too tight; because of this, and be- cause of the high tension of the heart muscles, the latter had been torn. The needle which was the cause of the accident was a very large one, with cutting edges. The holes made with the needle in the heart were fully one-eighth of an inch long. The strain upon the heart muscle was so great that the punctures were doubled in size. The autopsy also Plate XXXII. Experiment on the Heart, No. i6, page 269. i Experiment on the Heart. Xo. 18, page 270. Showing Silk Sutures ix Place. RESEARCH ON THE HEART OF THE DOG 2^1 showed that the coronary vein had been punctured, as well as the coro- nary artery. (Plate XXXII.) No. 19. August 21, 1901, 3.15 p. M. — Fox-terrier, age two years, weight 15 pounds. Chest cavity opened and pericardium divided. At this stage of the operation the operator accidentally thrust the tenaculum with which he was attempting to pull the pericardium up from the heart, in order to divide it, into the coronary artery. This is always a difficult pro- cedure, because the pericardium is so intimately united to the heart. A silk ligature was immediately applied to control the haemorrhage. This operation was performed so hurriedly that the needle used in ap- plying the ligature was passed through the pericardium, which was thus enclosed in the ligature. Respiration had ceased before the ligature could be appHed, but it was almost immediately restored on the artery being ligated. Blood spurted out with great force when the walls of the artery were penetrated, but it did not fill the pericardial space. It lost its fluidity with amazing rapidity, so that it remained quiescent, forcing the pericardium out like a balloon. The pericardium began to fill and stretch as long as the haemorrhage lasted. Doubtless the elastic tension of the pericardium aided also in preventing the blood from flowing into the pericardial space. All this combined to cause a clot to form very quickly. It also permitted the attachment of the fibrous elements of the blood, thus showing how fibrous, exudative adhesions are formed. Autopsy. Dog died August 25, 1901. Post mortem held 8.30 a. m., August 26th. Infection general. Abdomen distended with gas. No fluid in the thoracic cavity. Pericardium and pleura adherent to each other, and both adherent to the heart and chest wall. A bloody infiltra- tion into the mediastinal space, and also into the cutaneous structure, adjacent to the thymus gland. The adhesions consisted of fibrous bands. Both pericardium and the surface of the heart were covered with a granular exudate. PART II THE SURGERY OF THE LUNGS Plate XXXIII. First tracheal ring Impression for right subclavian arter)^ Upper lobe rtery Lower lobe Middle lobe Left lung Notch for the heart Esophageal impression Aortic impression AXTKRFOR \'lI£W OF THE LuNCS, Lower lobe (From Deaver's "Surgical Anatomy.") PART II THE SURGERY OF THE LUNGS INTRODUCTION No part or organ of the body is to-day held sacred from the surgeon's knife. As there are many pulmonary diseases which cannot be cured by the employment of the agents furnished by our modern materia medica, attention has been directed to the employment of surgical means to cure these conditions. But there are many practical difficulties to be settled before the surgical technique for pulmonary operations can be estabHshed on a firm basis. In order to devise an efficient and a successful tech- nique many experiments have been undertaken by dififerent workers. Wintrich, as early as 1854, made a series of experiments on animals. Pagenstecher nearly half a century later made another extensive series of similar experiments. The latter demonstrated that animals would survive both resection and excision of the lung. Other investigators have been successful in similar work. Still many little details remain to be settled. Many investi- gators do not say anything about their methods, and it is just these little details of technique that are needed. Some writers claim that experiments on animals, no mat- ter how successful, do not prove that man can safely undergo the same operations. 275 276 THE SURGERY OF THE LUNGS At the congress of French surgeons in Paris, 1895, Reclus condemned many operations for pulmonary diseases. He says, in regard to tuberculous diseases and primary cancer of the lung, that resection of the lung for these* conditions is " condemned past appeal." In criticizing an operator for cutting ofT the protruded part of a herniated lung, M. Reclus claimed that the term resection should not be applied to such procedures, because none of the healthy lung had been cut. No better word could be used: resection comes from two Latin words, the insepara- ble particle, re, and sectio, given by Andrews as meaning, a cutting of parts of the diseased body. Accepting the above authority, the word seems sufficient to characterize the operation of cutting ofif a gangrenous part of a lung. Reclus is one of those who believe that the results ob- tained by experimentation on animals cannot be applied to man. He says : "There is no reason in resecting the human lung, or in arguing from rabbits to men." M. Reclus is referred to because he represents a certain class of writers who decry all bold advances in the applica- tion of the results of experimental science. His criticism of published reports has some truth in it. It is quite true that sometimes only successful cases are men- tioned, and nothing said of the unsuccessful, but a surgeon is supposed to be familiar with the literature of his profession. Long before 1895 rnany cases were published of operations on the lungs, especially for those conditions in which Reclus condemns surgical interference. A relatively large number of resections for hernia of the lung have been tabulated. One table shows that 87^ per cent, are cured when operated upon; another that 85 1-7 per cent, are cured. In gangrene 60 per cent, recover after operation. About 71 per cent, recover when operated upon for bronchiectasis; INTRODUCTION 277 in tuberculous diseases 60 per cent, recover; in case of septic lesions 64.8 per cent, recover when pneumonotomy is em- ployed, and in case of aseptic lesions 75.8 per cent, recover. In a late list of 306 cases of pneumonotomy 218 recovered and 88 died. These figures ought to be conclusive evidence that surgical interference in these cases is justifiable. Many of the diseases enumerated above cannot be cured by other means, and any method of treatment that will cure sixty per cent, of what otherwise would be fatal should be employed. It is no excuse for a surgeon to let his patient die because surgery does not cure all cases, or because some prominent writer proscribes pulmonary surgery. If arguments from analogy have any force, the strongest possible argument for surgical operations for tuberculous diseases of the lungs can be drawn from the success of similar work in case of tuber- culous abscesses in the abdomen. Patients seemingly almost moribund are relieved, and recover from the operation in a surprisingly short time. Reclus's statement, " I know of no instance of operation for this disease in the lungs," speaking of actinomycosis, may have referred only to France. If not, it shows a want of knowledge of the history of pulmonary diseases. The decade preceding 1895 had numerous reports of cases of actinomycosis in man. The German surgeons and scien- tists wrote extensively on this subject, and there are a large number of cases of this disease invading the human lung. EngHsh and American writers also published cases. In considering the feasibility of pulmonary surgery the fact should be borne in mind that there are no diseases of any part of the body, or any organ, which are always at- tended by immediate fatality, and there are but few injuries of any one of the tissues or organs of the body which are necessarily fatal, if not immediately so. Hope is not to be abandoned under any circumstances, 278 THE SURGERY OF THE LUNGS the old proverb to the effect that, " where there is Hfe, there is hope," holding good, especially in diseases of the lungs. The diseases which are held to be incurable are not always so, because many instances have been recorded where they have yielded to some kind of treatment, or have been cured spontaneously. These facts are to be kept in mind when an apparently incurable case is encountered. Plate XXXIV. Anterior View showing Apex of Heart and Tissues. Posterior Mew. Normal Human Lung (Anatomy of the Lung.) TERMINOLOGY Pneumatelectasis imperfect expansion of the lungs Pneumochysis pulmonary oedema Pneumohaemia, or Pneumo- naemia congestion of the lungs Pneumokoniosis; pneumoco- niosis lung disease caused by inhalation of dust; anthracosis, when caused by coal-dust, coal-miner's lung ; siderosis, when caused by metallic dust ; chalicosis, when caused by mineral dust Pneumonalgia pain in the lungs Pneumonapoplexia a sudden hcemorrhage into the lung tissue Pneumonectasia, or Pneumo- nectasis emphysema of the lungs Pneumonemphraxis obstruction of the lungs or bronchi Pneumonemphysema emphysema of the lung Pneumonicula a slight inflammation of the lung Pneumonoblennozaemia pulmonary blennorrhcea Pneumonodynia pain referred to the lung Pneumonopathia any disease of the lung Pneumonoedema pulmonary oedema PneumonorrhcEa haemorrhage from the lungs Pneumonosyrinx a fistula of the lung Pneumonyperpathia any very grave disease of the lung Pneumoparesis progressive congestion of the lungs. due to faulty innervation Pneumophthisis a destructive process in the lung Pneumophyma a tubercle of the lung 279 280 THE SURGERY OF THE LUNGS Pneumophymia tuberculosis of the lungs Pneumonitis pneumonia Pneumonocholosis bilious pneumonia, or pneumonia accompanied with icterus Pneumonophlebitis inflammation of the pulmonary veins Pneumonoscirrhus induration of the lungs associated with bronchiectasis Pneumatosis air in abnormal places, or in exces- sive quantities Pneumocelcj Pneumatocele, Pleuroccle hernia of the lung (Pleurocele is sometimes used to denote a serous effusion into the pleural cavity.) Pneumoclasia rupture of the lung Pneumocace gangrene of the lung Pneumatodyspnoea emphysematous dyspnoea Pneumolith A stony concretion in the lung — sometimes used to denote a calcified tubercle Pneumomalacia abnormal softness of the lung Pncumosis, or Pneumonosis . . any affection of the lung Pneumonoscpsis septic inflammation of the lung Pneumorrhagia expectoration of blood from the lungs Pneumor desire for air, or to breathe Pneumonocarcinoma carcinoma of the lung Pneumoactinomycosis actinomycosis of the lung Pneumocentesis paracentesis of the lung Pneumonectomy or Pneumec- tomy excision of a portion of lung Pncumonotomy or Pneumoto- my surgical incision of the lung Pulmonarious affected with pulmonary disease Pulmoniferous provided with lungs TERMINOLOGY 28l Pleurapophysis a true rib Pleurapostema a collection of pus in the cavity of the pleura Pleurarthron the articulation of a rib Pleurarthrocace disease of the costo- vertebral joints; also caries of the ribs Pleuritis or Pleurisy inflammation of the pleura Pleuroclysis or Pleuroklysis ...injection of fluids into the pleural cavity Pleurocollesis adhesion of the pleural layers Pleurogenic or Pleurogenous . originating in the pleura Pleuron a rib Pleuropathia or Pleuropathy . . any disease of the pleura Pleuropyesis purulent pleurisy Pleurorrhagia haemorrhage from the pleura Pleurorrhoea effusion of fluid into the pleura Pleurostosis calcification of the pleura Pleurotomy incision of the pleura Bronchotomy a surgical cutting operation upon the bronchus, larynx, or trachea Bronchoplasty the surgical closure of a tracheal fissure or fistula Bronchophyma any growth, as a tubercle, in a bronchial tube. CHAPTER I ANATOMY OF THE LUNG The lungs are thin membraneous sacs, attached to the trachea. There are two sacs, known as the right and left lungs, made up of the ramifications of the bronchi, blood- vessels, nerves, and lymphatics, held together by areolar tissue. The external framework of the lungs consists of the pleura and the trabeculse sent down between the lobes and lobules. The right lung is shorter and broader than the left, and has three lobes, divided by two fissures; the left has but two lobes and one fissure. The pleura is formed of two layers, the external, a fibrous membrane, covered by large, flat, transparent, endothelial cells, and the subserous, or second layer, formed of loose areolar tissue, containing many elastic fibres, and in the lower animals non-striated muscular fibres. The pleura has a lymph system which communicates with that of the sub-pleural alveoli on one side, and by stomata with the pleural cavity on the other. The bronchi (properly bronchia— BpSyxo^, the old Greek word from which the modern term is derived) have their origin at the tracheal bifurcation opposite the third dorsal vertebra, and terminate in the pulmonary lobules, which are miniature lungs themselves. The primary tracheal branches are called the right and left bronchus. The right bronchus is shorter, larger, and more horizontal than the left, and enters the lung opposite the fifth intercostal vertebra, while the left bronchus enters the lung opposite the sixth dorsal vertebra, or 282 Plate XXXV. X IGO. Section of Injected Human Lung, (Showing- Air Cells). X IGO. Section Normal Human Lung. 554^ 565- Edwards, American Journal Medical Science, Philadelphia, 1885, n.s. XC, pp. 182-86. Maylard, Journal Anat. and Phys., London, 1885-86, XX, 34-38. LuKiN, Med. Prinban. Knoraksbornikin, St, Petersburg, 1885. pp. 423-428. Lamb, Medical News, Philadelphia, 1886, XLVIII, 181. KiRSCH, Bonn, 1889, 33. WoLLMANS, Dresden, 1891, p. 36. Reinhold, Miinich. Med. IVoch., 1893, 845-869. Bowles, Proc. Anat. Society Gr. Britain and Ireland, London, 1893, pp. 2-4. MoTTi, Gior. Internas. d. Soc. Med. Napoli, n.s., XV, 881-892. TiCHOMiROFF, Inter. Anat. und Phys., 1895, Bd. XII, 8-24. DuRCK, Sitz. d. Gesellsch. f. Morph. und Prms., Muench., 1895, X, 21. EcKLEY, British Medical Journal, London, 1895, I, 416. Bouchard, Bidl. de la Socicte d'Anat., Paris, 1896, XXXVIII, 344- Berchon Gazette dcs Hopitaux de Paris, 1896, XXXV, 447. Lawrence, Proc. Anat. Society, Great Britain and Ireland, 1896-97, XXX. Dumerin, Gould and Pyle's Anomalies et caetera of Med. Philadelphia, 1897. 294 "T^E SURGERY OF THE LUNGS Carper, Gould and Pyle's Anomalies et caetera. Philadelphia, 1897. WiSTAR, Gould and Pyle's Anomalies et caetera. Philadelphia, 1897. DiEMERBROECK^ Gould and Pyle's Anomalies et caetera. Phila- delphia, 1897. ScHAFFNER, Avch. Path. Anat., 1898, GUI, 1-25. Matthews, Proc. Anat. Society, Great Britain and Ireland, 1898, 34-38. Springer, Prag. Med. Woch., 1898, pp. 393-395- Carre, Paris, 1900. CHAPTER III EXPERIMENTAL RESEARCH (1795-1903)— INFLUENCE OF TRAUMA ON THE LUNGS AND HEART More than a century ago attention was turned to the experimental study of the lungs. Davidson's observations on the anatomy and pathology of the pulmonary system in 1795 mark the first recorded step in this direction. Some little time elapsed before Harlan, in 1819, showed by experi- ments on living animals, that the circulation of the blood through the lungs is immediately and entirely suppressed during expiration. Carson gave science the result of his re- searches on the elasticity of the lung in 1820. In 1832 ap- peared Caste's historical resume of the principal discoveries upon the structure and functions of the lungs. This is very valuable, especially to those interested in the history of medi- cine, and it is none the less so because of the practical ob- servations embodied in it. The next step forward was by Schiitzenburger, who, in 1832, published his studies on the physiological effects of certain dynamic lesions of the lungs. Rossignol, in 1848, gave the result of his researches on the respiratory organs of man and the principal mammals, thus completing the work of T. Addison on the anatomy of the lungs, and that of W. Addison on the ultimate distribution of the air passages, and the formation of the air-cells in the lungs. Certain problems were solved in 1847 by Sappy in his great work on the respiratory organs of birds. Cauman, in 1848, showed that the capillaries of the lungs do not anasto- 295 296 THE SURGERY OF THE LUNGS mose. Le Fort, in 1858, devoted himself to the study of the anatomy of the human kmg. Waters investigated the ultimate structure and distribution of the blood-vessels of the human lung. Bert, in 1869, brings us back to pure science by his work on the elasticity and contractility of the lungs, and the con- nection of these properties with the pneumogastric nerves. Brown's article on the alveoli of the lung containing squamous epithelium is a most concise one, and offers many suggestions concerning the repair of the lung tissue. D'Arsonval's re- searches (1887), theoretical and experimental, upon the part played by the elasticity of the lungs in the phenomenon of circulation should be consulted. Grehant (1879) brings us to the employment of physics in physiological investigation, by his study of endosmosis of gases in the detached lung. Casse, previously, had given the results of his experiments on the absorption and elimina- tion of gas by the internal organs of animals. Heger (1880) followed with his researches on the circulation of blood in the lungs. Roy and Brown (1885) showed that the bronchi contract under certain conditions. Gage (1885) showed the value and necessity of histologi- cal investigations, by his paper embodying the result of his study of the structure of the respiratory membrane in the pharynx of the soft-shelled turtles. The important work of Lamb (1886) showed that anomalous lobation of the lung is not infrequent, while the normal position of the lungs is a little more than an inch above the first rib. Cruveilhier was the first to show by the dissection of a foetus that one or both apices may extend along the cervical spine. Here it may be remarked, that the fact that the peri- cardium has never been found absent, should be remembered in eliminating its absence in herniated lung of the left side; it should also not be forgotten that the lower costal cartilages on the left side in women are rare. The cervical ribs are also Plate XXXVIII. X 40. X X 40. Sections Normal Lung of a Bird, (Martin). (Anatomy of the Lung.) EXPERIMENTAL RESEARCH (l795 — I9O3) 297 rare, as shown by post mortems; there are but two cases reported clinically. It is only in comparatively recent times that experiments have been made on the excision of the lung. Richard (1880) reported a penetrating wound of the thorax with immediate pneumocele. Excision of the lung was employed in this case, and the patient recovered. Schmidt (1881) gave the result of his experimental studies on partial lung resection; Block (1881) also made similar researches. In 1881 appeared Marcus's researches upon the experi- mental extirpation of the lung. Biondi followed with his reports on the same subject, and in 1884 published the results of the extirpation of the lung, following the experimental localization of a tubercle. Rcchcrchcs experiment ales et critiques stir I'ahsorption et I' exhalation pulmonaires are none the less interesting because Pagenstecher (1895), by his work upon rabbits, disproved those of Eintrich (1854), in which the latter found that blood introduced into the pleura would become absorbed without pleuritic adhesions after the eighth day. Mechanical injuries of the lung due to manipulation, con- tusion, stab wounds, gunshot wounds, et csetera, on the whole seem to affect the heart more than the respiratory organs. There is great difficulty in making satisfactory observations on this point. Some observations showed very marked " Vagel " heart beats on pinching the lung with the fingers. (Crile, "Surgical Shock," 1899, p. 129.) Mammals have a diaphragm, but the amphibia and lower orders of animals do not. (Byron Robinson, " Peritonaeum," 1897, p. 120.) Pinching the lung near the base of the heart produces irregular heart and a slight decline of the blood pressure. (Crile, "On Shock," 1899, p. 80.) The rhythm of the lung is controlled by the peripheral ganglia, or the auto- matic pulmonary ganglion which is situated in the lung sub- stance. 298 THE SURGERY OF THE LUNGS Crile ("Surgery of the Respiratory System," 26. edition, 1900, pp. 32-33), reports the results of his experiments upon a dog. He gave a blow over the right side of the chest dur- ing chloroform narcosis. He found that the respiratory action became irregular, with a marked fall of blood pressure. Reinboth's (1896-97) experimental study in lung dilata- tion, Crile's (1899) summary of an experimental research in the surgery of the respiratory system, and Carraras's (1898) mechanism of pulmonary lesions, are the only publications which have appeared in the last few years. Dr. S. P. Kramer, of Cincinnati, in 1900, injected agar- agar into the pleural cavity to fix the lungs. The success of this procedure encouraged him to inject it into hernial sacs to prevent recurrence of the hernia. There has not been sufficient time since to determine just how success- ful this method has been. But enough is known to urge him to carry on his experiments. Dr. Kramer claims that not only is the agar-agar absorbed, but there is evidence from microscopical examination that reorganization takes place. The cavity fills with connective tissue, at least there is new cell formation, which in structure resembles connective tis- sue. {Annals of Surgery, August, 1901, p. 273, Vol. XXXIV, No. 2.) BIBLIOGRAPHY Davidson, London, 1795. Harlan, Electrical Reporter, Philadelphia, 1819, IX, 122-128. Carson, J., Philadelphia Trans., London, 1820, CX, 29-44. Gaste, An. de la Med. Phys., Paris, 1832, XXI, pp. 236-278. Addison, T., Med.-Chir. Trans., London, 1840-41, XXIV, 146-154. Addison, W., Philadelphia Trans., London, 1841-42, XXXIV, 157-161. Cauman, New York Medical Journal, 1848-76, X, 27-32; Medical Gazette, New York, VI, pp. 31-32. EXPERIMENTAL RESEARCH (l795 — 1903) 299 Bert, Coiiipt. Rend. Socicte dc Biologie, 1868 (Paris, 1889), V, 55-57- D'Arsonval^ Paris, 1877. Grehaut^ Compt. Rend. Societe de Biologie, 1877 (Paris, 1879), IV, 429-432. Casse^ Bull. Acad, de Medicine de Belgique, 1878, XII, 652- 662. Garland, Pneumono-Dynamics, New York, 1878. Leyden, Charite-Annalen, 1878, III. BowDiTCH, Journal Phys., London, 1879, II, 91, 109, 1879.. HoMOLLE, Revue Mens., 1879, No. 2. LiCHTHEiM, Arch. f. Experim., Path., 1879. Richards, Indian Medical Gazette, Calcutta, 1880, VI, 213. Schmidt, Berlin. Klin. Woch., 1881, XVIII, 757-759. Block, Dent. Medical Woch., Berlin, 188 1, VII, 634-636. Marcus, Compt. Rend. Societe de Biologie, Paris, 1882, III, 323- D. BiONDi, Gior. Internaz d. Soc. Med. Napolia, 1882, n.s., IV, 759, 1883, n.s., V, 248-417. Brown, Lancet, London, 1884, II, 681. Gage, Proc. American Association Adv. Sc, 1885, Salem, 1886, XXXIV, 345-349- Lamb, Medical Nezvs, Philadelphia, XLVIII, 181 ; Klin. Vortr. 15 and 16, Vortr., Leipzig, 1889, F. C. W. Vogel ; Klin. Vortr. V. Resp. App., 6, F. C. W. Vogel, gr. 8, pp. 18; Gior. Internaz. d. Soc. Med., Napoli, 1894, n.s., Ill, 736-41. Reinboth, Deut. Arch. Klin. Medical, 1896-97, LVI, 178- 209. Carrara, Gior. di Medical leg., Lanciano, 1897, V, 161-173. Crile, Cleveland Medical Journal, 1899, IV, 57-81. Quincke, Deutsches Arch. f. Klin. Medical, XXI RosENBACH, O., Virchow's Arch., B. CV, No. 2. Schreiber, J., Deutsches Arch. f. Klin. Medical, XXXIII. VON ZiEMssEN, Klin. Vortr. v. Resp. App., 5, Leipzig, F. C. W. Vogel, gr. 8, p. 16. CHAPTER IV HISTORY OF LIGATURES AND SUTURES SusRUSTAS ( 1 500 B. c. ) WES the first to apply a ligature. He tied the umbilical cord of new-born babies before severing it. A passage in the writings of Hippocrates has been in- terpreted to mean that the Father of Medicine was familiar with the use of the ligature. Archigenes (100 b. c.) was the first to use ligatures in amputations. Celsus (30-25 B. c.^ A. D. 45-50) speaks of the ligature as something well known; he used ordinary linen thread. Galen (a. d. 13 1-2 1 1 ) advised ligatures to be applied at the proximal end of injured vessels; he favored the use of silk or fine catgut. Paulus yEgineta (a. d. 625-690) was one of the first to use the double ligature; he passed two ligatures beneath the ves- sel, which was then cut with a needle, each end of the vessel being closed separately. Jones, in advocating the use of the double ligature, only revived a method which had been practised twelve centuries before his time! Albucasis (died A. D. 1 105) recommended that a double thread of silk, or a cord used in instruments of music (catgut), should be em- ployed in ligation, especially in case of large vessels. The use of catgut is not, therefore, such a modern practice as some seem to think. Guy de Chauliac (1300- 1363) exerted great influence in the domain of surgery during the dark ages. He taught that the artery should be tied at the end that was nearer the heart or liver. Some of his remarks concerning the sects of his time are apropos to-day. He says: " The fifth sect is of 300 Plate XXXIX. 5|- --}rj^ ^ N ^ ^ \ "^^4,^ Whip Stitch. Herringbone Stitch. y 2 Mattress or Ouilted Stitch. Bell Suture. (Chapter on Sutures.) HISTORY OF LIGATURES AND SUTURES 3OI women and many fools, who refer the sick of all diseases to the saints solely, saying, 'Le Seigneur me I'a donne ainsi le nom du Seigneur soit beni. Amen.' " Leonardo Bertapaglia (died 1460) passed a needle, armed with a double thread, through the artery, tying both liga- tures firmly over each other. Alfonso Ferri (fifteenth century) claimed that the best ligature needle was one curved only at the point, with eye at the opposite end; the point should be quandrangular, and the needle not over three inches in length. Hans von Gersdorf (1517-1590), a German military sur- geon, applied ligatures in cases of vessel wounds, but pre- ferred styptics and cautery for amputations. Ambroise Pare (15 1 7-1 590) made free use of the ligature in amputations. But his great authority was not sufficient to secure the aboli- tion of the barbarous treatment by styptics and actual cautery. Such was the power of ignorance and prejudice that these methods continued to be employed at the Hotel Dieu until the time of Dionis (17 18). Pare was the first to use the twisted suture in hare-lip. Fabricius von Hilden (i 560-1634) is said to have intro- duced the use of the ligature into Germany. Hemp was the material employed by him. In England the ligature did not come into common use until some time after Harvey's great discovery of the circulation of the blood (1619), although introduced some years before by Wiseman (1566-1625). A surgical treatise by Peter Lowe, published in London (1596), is the first English work to mention ligatures. The old surgeons were haunted by the fear that the liga- ture would cut through the walls of the artery. Many de- vices were employed to prevent such accidents. Lorenz Heister (1683- 1758) used a stout ligature tied over a small cylinder of lint. All kinds of substances have been used for ligatures in an effort to secure a ligature that would not pro- duce the ill effects of the ordinary ligature. The old German 302 THE SURGERY OF THE LUNGS surgeons used hemp or linen ligatures. These substances are coming in use again; the French are making extensive use of hemp in the Parisian hospitals. P. F. von Walther was the first to propose the use of silk in Germany; but before Lister's great discovery all kinds of material proved more or less unsatisfactory. The use of the animal ligature was introduced in America by Dr. Physick in 1814. McSweeny brought the employment of silk-worm gut for ligatures into prominence in 181 8, al- though Wardorp had used it some years earlier. Sir Astley Cooper believed that catgut would give the best results. Dr. H. S. Levert, of Mobile, used elastic rubber rings. He also experimented with hgatures made of various metals. He secured primary union in every case in which he used metallic ligatures, or rather, metallic sutures. The expressions used seem to indicate that he sewed wounds with wire. Human hair was used by Porta. Paul Eve made use of the fibres of the tendons of deer. Dr. Stone, of New Orleans, tied the common iliac artery with a metallic ligature in 1859, and afterward he tied the femoral. Mr. Barwell used liga- tures made of the aorta of the ox. He tied the ligature only tight enough to approximate the intima. Dr. Ishigaro, a Japanese army surgeon, used a ligature made from the tendon of a whale. Marcy (1871) used kangaroo tendon for buried sutures, while Mr. Croft, in 1881, used it for ligatures. He tied the external iliac artery with kangaroo tendon during that year. Until the end of the eighteenth century the ends of the ligature were brought out through the wound. The practice of cutting the ends short is due to the efforts of Lawrence, although it is said that Haire, of Essex, had practised this procedure in 1786. Lawrence used dentist's silk for Hga- tures. An American naval surgeon, however, in 1798, adopted the practice of cutting short the ends of the knot. For many years it was held that it was the division of the two inner HISTORY OF LIGATURES AND SUTURES 303 coats of the artery which caused the adhesive inflammation that obliterated the vessel. Antonio Scarpa (1747-1832) proved, however, by his experiments, that the division of the coats of the artery was not necessary to produce this adhesive inflammation. The search for a material that would give the best possi- ble results as a ligature has been the " Philosopher's Stone " to surgeons. The good results that follow the use of a strictly aseptic ligature have been apparent to all, but animal ligatures are claimed by some to be the ligature par excellence, while others say that silk or silk-worm gut, or metallic liga- tures are the best. Again, others say that any absorbable ligature will produce good results, while still others pin their faith to non-absorbable ligatures. Silk and hemp have been objected to on the ground that they are liable to produce suppuration. Since the discoveries of Lister, Pasteur, and Koch, such objections have lost all force. The claim has been made in behalf of animal ligatures that they resemble in structure tire tissues in which they are placed. For this reason they are the best for permanent ligatures, and also because the continuity of the vessels is not necessarily destroyed. The extra-vascular cicatrix is also strengthened. By the use of the animal ligature the internal tunics of the artery remain intact, yet cicatrization occurs; hence they need to be tied with only sufficient force to approximate the surfaces of the intima. All that can be said in favor of the animal Hgature or suture has been found true with kangaroo tendon, but catgut is not reliable. There is great difficulty in securing catgut than can be thoroughly sterilized or that will stay where it is placed, or that will not break at the most inopportune time. There are other objections to the use of catgut. It has been claimed for catgut that it will not divide the tunics of an artery. Both Brun and Stimson proved by their experi- ments that it will divide the tunics. Stimson adds that the 304 THE SURGERY OF THE LUNGS adventitia also gives way under the pressure of the hg- ature. Mr. Barwell, who introduced the use of hgatures made from the aorta of the ox, claims that this material is not ab- sorbed, but becomes organized and forms an integral part of the neighboring tissues. Dent claims that his experience with ligatures of this material corroborates that of Barwell. Lister, however, thought they had misinterpreted the process observed. One prominent surgeon says, in reference to non- absorbable ligatures, that " all Hgatures, however, which permanently resist absorption, destroy the continuity of the vessels and weaken the vessel-walls at the seat of ligation." Silk when used for Hgatures does net cause this injury to the artery, but is partly absorbed and finally encysted, first being infiltrated with new cellular elements. It is true that non-absorbable ligatures, if aseptic, remain in the wound and become encysted, but it is not true that they are prone to destroy the continuity of the vessel-walls. Sometimes the adventitia is constricted to such a degree that vitality is suspended. In such cases the inner tunics, if healthy, are transformed into connective tissue, forming a band that closes the vessel. Under these circumstances the adventitia, after a slow process of disintegration and al^sorp- tion, is replaced by new cellular elements that are finally con- verted into similar tissue. There is nothing in these two processes that would interfere with the continuity of a vessel. A well-known surgeon of great experience says that in- jured veins are very liable to become infected. If this state- ment be true (and there is no reason to doubt it), every pre- caution should be observed to secure asepsis. At least every instrument or object used in operating and in dressing the wound must be thoroughly sterilized. Special care should be exercised to have whatever material is employed in ligating or suturing perfectly aseptic. In addition to ligatures there are various methods to se- Plate XL. W Combination of Mattress and Continued Stitches. Tug Stitch. Combined Tug and Tobacco Pouch Stitch. Glover's Suture. (Chapter on Sutures.) HISTORY OF LIGATURES AND SUTURES 305 cure bleeding vessels. Torsion and acupressure are the two principle modes, but neither is reliable. Torsion vessels will give way to a very slight increase of pressure, about six and one-half pounds; vessels closed by acupressure will stand an increase of about twelve to fifteen pounds to the square inch. But both methods would be useless in certain cases, especially in the lungs. Pollard, in 1869, devised a method similar to acupressure. He substituted a silver wire for the ligature, and brought the ends out through the skin covering the edges of the wound; the ends were then twisted together. Two other methods are of historical interest. R. X. Smith passed a wire (iron) through a silver tube to constrict the vessels. Six hours were sufficient to secure obliteration of fourth and fifth size arteries, and two days for the large vessels (femoral artery). Fabricius, however, anticipated Smith in the use of iron wire ; about the middle of the seventeenth century he recommended that an iron wire should be used for ligation. One end of the wire, which had been tempered, was to be sharpened and used as a needle. The so-called filo-pressure method was introduced in 1868 by Brun. A silk ligature, which had been passed around an artery, was brought out of the wound through a silver cannula having a cross-bar, the silk being fastened to the cross-bar. This method was used by Brun in his clinic for six years, and he claimed that it was perfectly satisfactory. There have been disputes also concerning the proper material to use for sutures. At this time there can be no question of the advisability of the closure of wounds with sutures. Now, only a smile of amusement is provoked by statements like Velpeau's, " if the employment of the suture . . . was not necessarily accompanied with much severe pain; if the union of the teguments was the most im- portant part of the operation . . . (sutures) would have been long ago adopted . . . [the objections omitted], in- 306 THE SURGERY OF THE LUNGS duces US to believe that for the future, except in a small number of cases, the adhesive plasters will continue to be substituted. There have been many efforts directed toward securing a material that would give satisfaction. It is not held by anyone to-day that any particular material is the cause of suppuration, although the ordinary explanation of the cause of infection may not be accepted. All will admit the good effects following the employment of aseptic material in sutur- ing. Catgut has its advocates for suturing, who, as a rule, insist more strongly on it being the best material for suturing than for the ligature; but all that has been said against its use as a ligature holds true as regards a suture. Even greater objections can be urged against its use. The use of wire or animal material for suturing is not alto- gether a new thing. Fabricius, of Aquapendente (1647), recommended metallic sutures. The other Fabricius (1537- 1619), a century earlier, in referring to intestinal wounds, speaks of animal sutures. The systematic use of animal, or rather catgut sutures, is said to have been due to Lister. John Morgan (1797-1847) is said to have been the first to employ metallic sutures. (Dennis's " System of Surgery," Vol. I, 1895.) A London surgeon, Mr. Gossett, in 1834, used silver-gilt wire for suturing in a case of vesicovaginal fistula. The publication of the results of Sir J. Simpson's experiments on animals drew attention to the use of metallic sutures in this country. Dr. J. Marion Sims employed metallic sutures in 1849. He is said to have been the first to use them in America. The use of metal for this purpose has been condemned, but like all non-absorbable material, silk-worm gut, et castera, metallic sutures do no harm. In some cases they are of great utility in preventing after trouble. It is only in a few positions that metallic sutures could cause any inconvenience. Silk or wire very rarely cause trouble by working out to the HISTORY OF LIGATURES AND SUTURES 3O7 surface. The most important point in their favor is that they can be perfectly steriHzed. In a work deahng with the surgery of the lung it may be of interest to give an account of certain methods that have been used to secure arteries of the chest, especially the inter- costal. Goulard, of Montpelier, invented a special needle for this purpose. This needle formed three-fourths of a circle, with the eye near the point, which was somewhat blunt. The ligature lay in the concavity of the needle; to facilitate its use, the needle was attached to a long handle. Lottery, of Turin, constructed for this purpose a steel plate, which was narrower at one end than at the other; at the narrow part it curved in two directions. Holes were punctured in the curved part of the plate, to fasten the compress for the artery. The instru- ment was secured by narrow strips of cloth which passed through slits in the broad end of the plate. The plate was introduced into the wound in such a manner that the lower edge of the rib rested in the concavity of the plate, and, of course, the compress acted on the edge of the rib and artery. Quesnay employed a piece of ivory covered with lint. The instrument was drawn from within outward, compress- ing the artery by means of a ribbon. Belloc also invented an instrument for the same purpose. It consisted of two plates, padded, which could be approximated by a screw. CHAPTER V PNEUMONOTOMY— PNEUMONECTOMY— PNEUMONOR- RHAPHY — PNEUMONOPEXY — BRONCHOTOMY — GENERAL AND LOCAL AN^STHESL\ Pneumonotomy is a compound Greek word. 7n/ei;/iO)j/ to^tj, meaning a cutting of lung. It is more descriptive and should supplant all other words for cutting operations upon the lung. Pneumotomy, pneumonectomy, and various other terms and expressions have been applied, but not until 1890 was the word pneumonotomv adopted, and then by De For- rest Willard. Since that time it has only been occasionally used by various operators for the opening of cysts and ab- scesses. Pneumonectomy means the removal of a part or all of one or more lobes of the lung. It is resorted to in many cases of laceration, new growths, hernia, and gangrene of the lung. PueumonorrJiaphy (suturing the lung) has been success- fully accomplished many times for injuries and after opera- tions, for the removal of foreign bodies, hernia, gangrene, cysts, and new growths. Absorbable and non-absorbable sutures are either absorbed or become encysted in the lung tissue, so that one need not hesitate to use sutures of any accepted material in emergency surgery of the lung. Pneiimonopexy (anchoring the lung to the chest wall) is sometimes desirable in dealing with the lung stump after amputation for hernia or laceration, or after an abscess or cyst has been opened for drainage; also where there is doubt as to securing pulmonary vessels in injuries or operations 308 PNEUMONOTOMY — GENERAL AND LOCAL AN^STIIESL\ 309 upon the lung. There are but few cases where it would proba- bly be best to anchor the lung to the chest wall, thus re- quiring two sittings for opening cysts or abscesses. Bronchotomy (cutting into the bronchus) is done for the removal of foreign bodies and polypi. The point of attack may be through the anterior or posterior chest wall. This is one of the most difficult operations of the lung, because the lung itself must be divided before the bronchus can be opened. Historical (1714-1903). — Fabricius Hildanus (Opera omnia. Francof. A. M., 1646) and Ruysch (Opera omnia. Amsterodami, 1737) have recorded cases in which large por- tions of the lungs have been excised and patients recovered. Baglion advocated operations on the lungs as early as 1714, and Barry indorsed the doctrine of Baglion ten years later. ("Treatment of Consumption of the Lungs," p. 217, Dublin, 1726.) Hale {Medical Exam., Philadelphia, 185 1) referred to a case of penetrating wound in the chest in which recovery followed the removal of a piece of the lung. Willard (1891) made an intrathoracic bronchotomy from behind for a for- eign body impacted in the bronchi. Even though he was not permitted to complete the operation, owing to the ex- hausted condition of the patient, he demonstrated beyond peradventure the feasibility of the operation under proper environments. His experiments were especially valuable in that many vexatious problems concerning the suturing of lung tissue were solved. One prominent writer says: "Although some animals have survived complete extirpation of a lung, man has not." Although there is but one case recorded where man has sur- vived a primary operation involving the extirpation of either the right or left lung, there are many cases on record where one or the other of the lungs has been destroyed by disease or trauma and the patient has survived. There are, too, cases 3IO THE SURGERY OF THE LUNGS lately recorded of the extirpation of a lung, but it is not clearly stated whether the patient recovered or not. Kurz wrote extensively upon lung surgery. Grumwald and Manquat each speak of lung surgery during the year 1891, which saw so much published concerning surgery of the lung. Krecke during the same year gave a most inter- esting history of lung surgery. Bechini (1891) published a paper on the application of surgery to the lung in grave cases, as did Roux. Guermonprez (1892) described a new method of suturing the lung. TufBer (1892) added much to this special department of surgery by his research. Wills (1892) described his experimental study in pneumonectomy and lung suturing. Richerole (1892) mentions " pneumo- nectomie " in an address upon lung surgery. Delagnere (1894) contributed an essay on his observations on the sur- gery of the pleura and the superior lobes of the lung, as did Heydweiller (1894) in a work on the surgery of the lung. Rodman (1894) made a pneumonotomy. Tuffier (1895) again mentions a new method for the surgical exploration of the lungs. Artman (1897) also pubHshed a critique on lung injuries and on the present status of lung surgery. Beck (1897) published his technique of pneumonotomy. Merelli (1898) resected the pulmonary cartilages. For other ob- servers who have reported new methods and interesting cases see Bibliography. Karewski (1898) and Kopstein contribute valuable thoughts on lung surgery. Herzfeld (1898) and Mayo (1898) also reported cases of pneumonotomy. Malbot (1898) pub- lished a paper on the surgery of the lung. Kohler (1898) published a work on pulmonary surgery; those interested in this branch of surgery will find this work very valuable. Riedel (1898) published his observations on lung surgery. Augros published a paper (1898) on the treatment of chronic empyaema. Sonnenberg (American Medicine, July, 1901) has formu- Plate XLI. Anti-iracosis IX Cancerous Lung. (Chapter on Foreign Bodies.) PNEUMONOTOMY— GENERAL AND LOCAL ANAESTHESIA 31I lated the following law regarding pneumonotomy : "If the pulmonary tissues are hard, divide them with a knife, as there is no danger of haemorrhage; if the pulmonary tissues are soft, divide them with the cautery, as there is great danger of hemorrhage." It has been the author's experience that the use of the fingers to divide the tissues gives the best results in the latter case. When pneumonotomy or pneumonectomy is undertaken for tumors or tuberculosis, Koenig says : "To perform such an operation the surgeon must ignore absolutely all his knowledge of pathology." Tuffier, in his Moscow address, gives an analysis of three hundred and six pneumonotomies. There were ten recoveries in fifty-five cases of metapneu- monic gangrene; three in four cases of gangrene with ectasia of the bronchi; two recoveries in seven cases of embolism; one from a gunshot wound. In forty-nine cases of abscess of the lung, mostly encapsulated intralobular suppurating pleu- ritis, twenty-three per cent, succumbed to the pneumonotomy; three cases of incipient tuberculous foci were cured, but the operation in cavities was followed by death in thirteen out of twenty-six cases operated on. Ombonin and Michaux's cases were gunshot wounds; De Lormes's a stab. The first died from infection; the second from exhaustion, thirty minutes after the operation; and the third made a perfect recovery, the wound having been packed with gauze to prevent haemorrhage. The open cavities rarely cicatrized, and only one or two were improved. Intra- parenchymatous injection in tuberculosis also proved inef- fectual. No primary neoplasms have yet been operated upon, but seven cases of sarcoma that have extended to the wall over the lung were operated on. For these difficult opera- tions he resorts to trachaeal insufflation with respiration by pressure through a tamponed cannula introduced into the larynx. He rejects puncture in hydatid cysts, as unreliable and dangerous, from possible perforation of the bronchi. 312 THE SURGERY OF THE LUNGS There are twenty-nine operations on record for aseptic lesions of the King, with twenty-two recoveries, seventy-five and eight-tenths per cent., and seven deaths, twenty-four and one-tenth per cent. This includes traumatic lesions, hernise, neoplasms, and tuberculous nodules. Sixty-one operations were performed for hydatid cysts, with fifty-five recoveries and six deaths. The remaining two hundred and fifteen were performed for septic lesions, with one hundred and forty re- coveries, or sixty-four and eight-tenths per cent.; seventy- five deaths, or thirty-five and two-tenths per cent. This includes tuberculous cavities, thirty-six cases with thirty- six deaths; abscess, forty-nine cases with twelve deaths; bronchiectasis, forty-five cases with thirteen deaths; foreign bodies, eleven cases with four deaths; gangrene, seventy- four cases with thirty deaths; actinomycosis, one case, not fatal. Total, three hundred and six cases; cured, two hun- dred and seventeen; died, eighty-eight. {Journal Amer- ican Medical Association, January 15, 1898, p. 169, Vol. XXX.) B. Bell fearlessly and successfully opened abscesses in the lung, no matter at what depth they were situated. Sapie- joks stated that he located adhesions with an exploratory needle, connected with a manometer; when the point of the needle projected into an open space, the manometer was lowered, while it remained stationary if the needle encoun- tered adhesions. Operative Technique.. — Emergency. In this class may be included the cases of severe haemorrhage (due to injury or disease), hernia, foreign bodies, and those surgical conditions produced by, or resulting from, delay in advanced pathologic changes. Election. In this class are to be included those cases in which ample time is given to analyze conditions and decide upon a certain definite course to pursue. There is but little variation in the course to pursue for PNEUMONOTOMY — GENERAL AND LOCAL AN^STHESLV 313 the incising of lung tissue, removal, suturing, or anchoring to the chest wall (internally or externally), so far as the preliminary work for their performance is concerned. The same surgical principles should be maintained in asepsis, opening and closing the chest, with or without drainage, to- gether with the postoperative treatment. The operator should prepare for artificial respiration in all cases of opera- tions on the lungs. He should have a supply of oxygen at hand, with the necessary apparatus to use it. He should also have a number of assistants present, in case it should be necessary to employ artificial respiration. The surgeon must also be prepared for tracheotomy if other means fail. In asphyxia a laryngeal cannula may be used, with bulb to produce strong artificial respiration. (Journal American Medical Association, January 15, 1898, p. 169.) It is well to have strychnine, a battery, bellows, hot water, etc., at hand, with means of rectal divulsion. Pneumonotomy is the only probable means of relief in cases of hydatid cysts, localized gangrene, and abscess. When resorting to this operation, the exact seat of the disease is first determined by the usual means. If adhesions are present, aspiration is, perhaps, a most important means. Then the superficial tissues are divided and one or more ribs resected, as may be necessary, care being taken not to injure the pleura. (In case of adhesions, it is the practice of some to discard the knife and use actual cautery heated to a dull red glow.) The seat of the disease having been freely laid open, the patient is rolled over to encourage the outflow of fluid. Drain- age by gauze or tube is established and haemorrhage is checked by pressure. When there are no pleural adhesions, the operation is more difficult and the prospect poor. Sutur- ing the lung to the chest wall before making an incision of the pleura is difficult, and does not always prevent partial pneumothorax. Do not irrigate, as it is liable to drown the patient. 314 THE SURGERY OF THE LUNGS Sterilization may be general, local, or both. It is es- pecially desirable that the field of operation be cleansed. However, there are cases where necessity and environment will preclude the possibility of the least attempt at cleanli- ness, which might result in the loss of a life, or serious compli- cations that would overshadow the benefits to be derived. This is especially the case when the internal mammary and larger blood-vessels have been injured. If time is sufficient, every precaution should be taken. The field of operation should first be cleansed with soap, water, alcohol, turpen- tine or benzine, and not only the skin, but the fabrics to be used in the operation and in the care of the case should also be clean. General and Local Anaesthesia. — No anaesthesia is necessary when a state of unconsciousness prevails. General anaesthesia is to be employed in emergencies as a rule, if patient is con- scious, and also in the majority of cases of election. Chloro- form is to be preferred because narcosis is obtained quickly and with less resistance. Local anaesthesia can seldom be employed in emergencies owing to its uncertainty and the time required to be effectual. Ethyl chloride and cocaine are the most desirable agents. Local anaesthesia may, how- ever, be frequently employed in cases of election. Opening in Chest. A curved cutaneous incision (with the point of entrance of the weapon in the chest and the point to be attacked in the centre of the circle) will enable one or more ribs ro be divided by the forceps in a semicircle ; its extent and direction must be governed by the necessity for drainage. Great care should be exercised in not allowing instruments to enter the pleural cavity before the lung has contracted upon itself, as the result of air entering the chest. If the chest remain open, the lung will be contracted, but if the opening becomes closed by clots or otherwise, the lung will again expand. A contracted lung is desirable at time of opening the chest because of the danger of injuring it. It Plate XLTI. f , ■4 '•'■ ?''■■'<„- ^J^'i»€ ^^^>&' X IT.T. GEdema of Lung. X lor,. Poly L- us. (Chapters on Benign Tumors and CEdema.) PNEUMONOTOMY — GENERAL AND LOCAL AN^STHESLV 315 can be made to contract by reopening the wound and allow- ing air to enter the chest, just previous to operating. There is but little bleeding in dividing the soft and bony structures of the chest, unless the internal mammary artery is severed. The intercostal arteries cause but little annoy- ance. If they do, they may be ligated, or crushed with forceps. Both the distal and proximal extremities of the internal mammary artery should be ligated. The existence of adhesions of the parietal to the visceral pleura is desira- ble when the lung is to be incised for cysts, or for the re- moval of foreign bodies, but their induction is not necessary before opening the chest. An opening in the chest permitting ample space for work is essential, and no time should be lost in accomplishing it. All clots within the pleural cavity should at once be removed with the fingers, and gauze used to keep the lung clean until the wound can be found. Once discovered, a pair of long-handled artery forceps may be applied. If the bleed- ing is not severe, it may be controlled by firmly packing gauze into the open wound of the lung. Either one of these pro- cedures will permit of ample time to decide upon the proper course to pursue. The situation well in hand, a silk ligature may be appHed to the artery, and a suture of the same mate- rial used to close the laceration in the lung tissue, if it be proper. If the laceration involves the border of one or more lobes, the lung may be brought out of the chest cavity and the work completed before it is returned. The ragged portion of the lung may be ligated en masse by transfixion, and the lung returned to the pleural cavity. All bleeding vessels being secured, the pleural cavity freed from all clots and for- eign material, the chest may be temporarily closed for a few moments, by coapting the cutaneous structures, or by placing the hand over the opening in the clTest to allow the lung to expand, and to be assured that all ligatures are in their 3l6 THE SURGERY OF THE LUNGS proper places. This once determined, the chest can be at once closed, with or without drainage, as the case may re- quire. BIBLIOGRAPHY Baglion et Barry, Dublin, 1726, p. 217. Dease, Dublin, 1778. DucHATEAU, Strasburg, 1822. Mesterman, Strasburg, 1828. Martin^ Paris, 1854. Fowler, Tr, Medical and Surgical Society, London, May 31, 1874. Weist, St. Louis Medical and Surgical Journal, 1880, XXXIX, 715-717. Trader^ St. Louis Medical and Surgical Journal, 1881, XL, 123-129. Thomas, British Medical Journal, London, 1885, II, p. 692. RocHETT^ IVicn. Mcdicin. Presse, 1886, 1266. RuDiNGER, Deutsche Arch. f. klin. Medicin., 1887, XLl. OsLER, Johns Hopkins JJospital Bull., Baltimore, 1889-90, L, p. 109. MooRHOF, Wien. Medicin. Presse, 1889. Tafurt^ Miinch. Medicin. lVoch.,i8gi, 6-9. Bull, Mag., f. Laegeriderisk (Norsk), Christiana, 1891, 4 R., 289-292. Taufert, Uber Lungenchirurgie, 1891. Krecke, Beitrage zur Lungenchirurgie. Miinch. IVoch., 1 89 1, 399-401. Bacchini, Medical Fcrdi., 1891, s., XI, 561-567. Roux, Bull, et Mem. Societe de Chirurgie, Paris, 1891, n.s., XVII, 442-444- Davies, New Zealand Medical Journal, Dunedin, 1890-1891, IV, 249-253. HuBER, Medical News, Philadelphia, 1891, LXIX, 455. KuRz, IVien. Medicin. Presse, 1891, XXXII, 1 389-1 392. PNEUMONOTOMY— GENERAL AND LOCAL ANESTHESIA 317 Grumwald, Miinch. Medicin. Woch., 1891, 699, 701, 721. Manquat, Bull, Gen. de Thcrap., Paris, 1891, LXXI, 305- 313- WiLLARDj American Journal Medical Science, Philadelphia, i89i,n.s., CII, 565-578. Laach, Norsk Mag., f. Laegevidensk., Christiana, 1891, 4 R., VI, 293-315. TiETZE, Deutsche Zeitschr. f. Chirurgie, Leipzig, 1891-92, XXXII, 438-524. VON Kerchoff, Liedes, 1892. RocHARD, Gazette d. Hop., Paris, 1892, LXV, 281-289. Hagentorn, St. Petersburg, 1892, IV, 53-55. Wills, South California Practitioner, Los Angeles, 1892, VII, 167-175. Richerole, Paris, 1892, p. 95. Guermonprez, Gazette d. Hop., de Toulouse, 1892, VI, 257. Malpeli, Gazette d. Hop., Milano, 1892, XIII, 1026-1028. GuermonpreZj Journal de Science Medicate de Lille, 1892, II, 221-226. Monod, Bidl. et Mem., Societe de Chirurgie, Paris, 1892, n.s., XVIII, 578-580. HoFMRKLj Wien. Medicin. Presse, 1892, 1905-1948. Tuffier, Bidl. et Mem. Societe de Chirurgie, Paris, 1892, n.s., XVIII, 726. Tuffier, Wien. Medicin. Presse, 1893, 681-684. Tuffier, Wien. Klin. Woch., 1893, 68. Lawson, British Medical Journal, London, 1893, I, 1152- 1154- PiCKARD, Canadian Practitioner , Toronto, 1893, XVIII, 433. Trzebicky, Wien. Medicin. Woch., 1893, 905~956- Pitts, Lancet, London, 1893, II' 615, 678. 735, 795, 915. MiJLLER, Deutsche Zeitschr. f. Chirurgie, Leipzig, 1893. XXXVII, 41-49. Delageniere, Arch. Prov. de Chirurgie, Paris, 1894, III, 1-42. Heyweiller, Berlin, 1894, p. 307. 3l8 THE SURGERY OF THE LUNGS Lopez, Sigh Medical, Aladrid, 1894. XLI, 198-200. Karotta,, Osaka Igakii, Lenkukwan, Zashi, 1894, No. 18, 12- 17- Omer, Lyon Med., LXXVI, 438. Rodman^ American Practitioner and News, Louisville, 1894, XVIII, 222. Llobat, Rev. de Chiriirgie, Paris, 1895, 242-245. Reclus, Gazette Hebd., Paris, 1895, XLIII, 482-489. TuFFiER, Semaine Medicate, Paris, 1895, III. 522. Richard, Semaine Medicate, Paris, 1895, XV, 508. TuFFiER, Gazette d. Hop., Paris, 1895, LXVIII, 1320. Bloxdi, Chirurgie, ]\Iilano, 1895, III. 425-459. Terrier, Surgery of the Lung, F. Alcan, 98 p. D'AziNcouRT, Paris, 1896. RiCKETTS, B. ]\I., Clinic, Cincinnati, September i, 1896, Vol- ume XXXVII, p. 22,7. Paget, Surgen,^ of the Chest, London, 1897; Bull, et Mem. Societe de Chirurgie, Paris. 1897, XXIII, 76-93, 105-130. FuNNiN, Suppl. d. Policlin., Roma, 1897, 1898, IV, 1309- 1312. Fuxxix, Med. Mod., Paris, 1897, VIII, 521-524. Altman, Vrtjsch. Gerich Med., 1897, XIV, Suppl., 71-106. Hadra, Vernadi. d. Chirurgie, 1898, XXVII, pt. L, 80-89. Doyen, Revue d. Therap. Med.-Chir., Paris, 1898, LXV, 37^ 43- Tait, Medical Neii's, New York, 1898, LXXII, 263-266. Karewski, Arch. Klin. Chirurgie, 1898, LVII, 555 590. KopsTEix, Lasop. lek. cesk. v. Prage, 1898, XXXVII, 345-349. Herzfeld, Deut. Med. Woch., 1898, p. 193. Mayo, North Western Lancet, St. Paul, 1898, XVIII, 441. Malbot, Arch. prov. d. Chirurgie, Paris, 1898, VII, 707-724. KoHLER, Berlin Klin. Woch., 1898, 337-341. RiEDEL, Miinch. Med. Woch., 1898, p. 888. AuGROS, Lyon Med., 1898, p. 76, No. 94. LiciiTENAUER, Dcutsche Zeitschr. f. Chirurgie, 1898-99, I, 389-394. Plate XLIII. X llo. LYMPHOMy\. ♦ • % M X 250. ClIRONDROMA. (Chapter on Benign Tumors.) PNEUMONOTOMY — GENERAL AND LOCAL ANESTHESIA 319 Solomon^ Revue de Chirurgic, Paris, 1899, XIX, p. 284. Murphy, XIII Cong. Internat. de Med., sect. de. Chir. Gen. 1900, Paris, 1901, Coiiipt. rend., 595-598. TuFFiER, Gangrene piilmonaire, pneumonotomie, apparition de bacilles turberciileux dans les crachats au cours du traite- ment, guerison sans symptomes de tuberculose pulmonaire depuis un an. Bull, et mem. Soc. de Chir., Paris, 1900, XXXI, 342. Jordan, A., Rev. Vol. de cien. Med. Valencia, 1900, II, 72-78. Cristovitch, M., Pneumotomie avec resection costale pour plaie grave du poumon par arme a feu, guerison. Rev. Med.-Pharm., Constant, 1900, XIII, 85-86. Jacobson, O., Therap. d. Gegenwart, Berlin, 1900, III, 305^ 312. Lane, G., A plea for early operation in cases of undoubted tubercle of the lung. Lancet, London, 1900, II, 134-135. Rose, Ein fall von zerreissung der lunge des herzbeutels und des zwerchfells (Haematopneumothorax pneumopericar- dium und pneumoperitoneum). Deutsch med. Woch., Leipz. u Berlin, 1900, XXVI, ver-beil, 186. Herczol, E., Wien. Med. Presse, 1900, XLI, 2321-2324, 2375, 2379 ; I %• TuFFiER, Pneumotomie pour ectasies bronchiques multiples. Bull, et Mem. soc. de Chir. de Paris, 1900, XXVI, 242, 243, 247, 249. Koch, C. F. A., Enkele gevallen von pneumotomie Nederl. Tijdechr v. Genessk., Amsterdam., 1900, 2 R, XXXVI, d. 2, 911-925; 4 fig. Stade, Fritz, Inaug Diss., Kiel, 1900, Juni u. Juli. Herman, M. W., Prezgl lek., Krakow, 1900, XXXIX, 317- 318. Herman, M. W., Gazz. Med. di Torino, 1900, LI, 668-673. Meyer, Paul, Gazs. Med. di Torino, 1900, LI, 709-715. Parascondolo, C, Arch. Internal, di med. e chir., Napoli, 1900, XVI, 419-448, 449-492. 320 THE SURGERY OF THE LUNGS Kareswki, Verhandl. d. zver f. inn. Med. mi Berlin, 1900, XIX, 192-195. W. H., The surgery of the tuberculous lung. Polyclin., Lon- don, 1900, II, 347-348. VuLLiET, H., Gangrene pulmonaire, pleurotomie et pneumon- otomie. Rev. med. de la Suisse Rom., Geneve, 1900, XX, 67-73- Macalister, C. J., Puncture of the lung in chronic pneu- monic conditions. Liverpool Med. Chir. Jour., XXI, 16-20. Weinberger, M., Ztschr. f. Heilk., Wien u. Leipsic, 1901, n.f. II, Med. int. 78-104, 5 taf., i abb. Barbieri, p., XIX An. de San. mil. Buenos Aires, 1901, III, 38-54. Delageniere, H., Du pneumothorax chirurgicale ; ses dangers et sa valeur au point de vue de la chirurgie pleuropulmo- naire d'apres six observations. Arch. prov. de Chir., Paris, 1 90 1, X, 709-727. BoRCHERT, F., Arch. f. Klin. Chir., Berlin, 1901, LXIII, 400-463. BoRCHERT, F., Inaug. Diss., Berlin, 1901, Marz-Juni. Samland, F., Zur operativen behandlung der granulose unter besonderer beriicksichtigung der gegen dieselbe gemach- ten einwande und der rezidivfrage. Inaug. Diss., Leipzig, 1 90 1, November. Karewski, Med. IVoch., Berlin, 1901, II, 324-327. Semprun, Oto-ribo-laringol espan., Madrid, 1901, IV, 9-13. BuLLARD, Atlanta, Georgia, Journal Record of Medicine, De- cember, 1 90 1. Rose and Careless, Surgery, 1901. Morrison, Charlotte Medical Journal, North Carolina, Decem- ber, 1 90 1. AiME, Paul Heineck, Medical Standard, Chicago, 111., De- cember, 1 90 1. Lenhartz, Medicin. et Chirurgie, Jena, 1901, IX, 3, p. 338. Garre, Medicin. et Chirurgie, Jena, 1901, IX. 3 p., 338. PNEUMONOTOMY — GENERAL AND LOCAL AN^iSTlIESIA 32 I Lemke^ American J our. of Surgery and Gyn. St. Louis, Janu- ary, 1902. LeBoutillier, Nezv York State Journal of Medicine, January, 1902. DoLLiNGER^ J., Der artificielle pneumothorax als vorbereitende operation zur extirpation durchgrei fender brustwandtu- moren oder Lungentumoren. Centralhl. f. Chir., Leipsic, 1902, XXIX, 82-83. Delageniere, H., Du pneumothorax chirurgical; ses dangers et sa valeur au point de vue de la chirurgie pleuro-pul- monaire d'apres deux observations. Paris, I. B. S., 1902, 19 p. Garre u Sultan, Kritscher bericht iiber 20 Lungenopera- tionen aus der rostocker und der Koeniksberger. Klinic Beitr. s. Klin. Chir., Tiibingen, 1902, XXXII, 492-531. Packard and Le Conte, American Journal of Medical Sci- ence, March, 1902, p. 375. Huber, Philadelphia Mcdicin Journal, May, 1902, p. 803. Settimi, Gazette Med. di Roma, April, 1902, p. 197. Ungar, Zeitschrift fiir Medical Beamte, Berlin, XX, 12 p. 417. KoRTEWEG, T. A., Annals of Surgery, Philadelphia, Pa., July, 1902, p. I. RiY.G'i^-ER, Deutsche Med. Woch., Berlin, July, 1902, p. 515. Garre and Sultan, Deutsche Arch. f. Klin. Chirurgie, 1902, XXX, ii. Theodoroff, S. p., L'echinococcotomie transpleural d'apres leprofesseur Bobroff. Chirurgia, Moskwa, 1902, XI, 285- 292. CHAPTER VI GUNSHOT, LACERATED AND INCISED WOUNDS GUNSHOT WOUNDS — Injuries of the lungs, due to gun- shot and explosive missiles, are more common than those of any other type, and their character has changed materially within the last twenty-five years. The quality of the ex- plosive, the kind of weapon, the size, quality, shape, and velocity of the ball, have all undergone a great evolution. The ball is smaller, harder or softer, travels further and faster, so that its destruction to soft tissues is greater or less than formerly. If the ball is harder, the destruction is less; if softer, the destruction is greater under the same circum- stances. The velocity and distance being so greatly increased cause the ball to become heated to such a degree as to make it aseptic at the time it comes in contact with, and continue so until after it has left the body. In consequence of this heat the walls of the tract through which it has passed are also made aseptic. The small modern steel ball has been known to pass through every organ, including the heart and brain, with- out producing death. The kidneys, lung, liver, spleen, and pancreas have each been perforated in such a manner without fatality. Historical — One of the earliest accounts of such wounds is that of Mallet (1743), who published a report of a lad who was shot through the lung. Rigby (1790) reported a case of recovery after a ball had passed through the lung. In 1800 Home's very satisfactory account appeared. This 322 GUNSHOT, LACERATED AND INCISED WOUNDS 323 was a case of a person who was shot through the lung and survived for thirty-two years. The account contained a description of the appearance of the contents of the thorax after death. Keys (1845) reports a case where balls perforated the diaphragm and left lung in two places. Campbell (1846-47) had a case of gunshot wound of the lung, in which the patient recovered. Moore (1847) tells us of a case where the ball was lodged fifty years in the lung. Beal (1847) observed a case of gunshot wound where a portion of the right clavicle was carried away, and the bullet passed through the summit of the lung and scapula; the patient recovered. Eve re- ported the well-known case of General Shields, who was shot through the body by a grape-shot at Cerro Gordo. In this case the grape-shot had evidently entered the right nipple, passed between the lungs, through the mediastinum, and emerged a little to the right of the spine. Longmore (1855) also reported a recovery from a severe injury to the chest and wound of the lung by grape-shot. Upshur (1855) re- ported a case of gunshot wound of the lung. Warren (1857) described a case where pistol balls were suspended within the chest by the pleura; also the appearance of the thoracic cavity eight years after the gunshot wound. Peters (i860) had a case of severe gunshot wound of the left lung, in which the patient recovered. In 1 861 the treatment of gunshot wounds of the lung was given an impetus by Clapp's publication of cases of gun- shot wounds of the right lung and their treatment. The same year Sinn reported a case of gunshot wound of the right lung with discharge of pieces of lead from the mouth, seven weeks after the injury; recovery took place. Farns- worth (1865) had a case of gunshot wound through the chest. Roustan (1865) reported a case of gunshot wound of the lung, in which the lead ball became encysted. Forments ( 1866) had a case of gunshot wound penetrating the left lung; the ball 324 THE SURGERY OF THE LUNGS remained. There was apparent recovery, with recurrence of symptoms two years after the injury. Johnson (1867) noted the absence of symptoms in a case of gunshot wound through the bottom of the lung. Eve (1867) reported a case of penetrating wound of the left lung in an infant, the ball passing near the heart; the patient re- covered. (Circular No. 3, War Department, Surgeon-Gen- eral's Ofifice, August 17, 1871, may be consulted for reports of cases of penetrating gunshot wounds of the chest with recovery.) Woodson had a case of gunshot wound of the right lung and shoulder joint. Wright reported a case of bullet wound of the right lung in a child three and one-half years old. (An interesting w-ork on this subject is that of Chaplain on Lung Wounds by Firearms.) Keller (1874) re- ported a gunshot wound of both lungs, and Lewis (1874) reported a case of gunshot wound of the left lung, produc- ing large pleural efifusion; paracentesis thoracis was performed by the aspirator, followed by free incision of the chest wall and convalescence of the patient. Crawford (1879) reported successful treatment, by blood- letting, of a gunshot wound of the chest, involving both lungs, and complicated wdth fracture of the scapula, with paralysis of the left arm. Ombonin, of Cremona (1885), De Lormo (1893), and Michaux (Congres Franqais de Chirurgie, 1895), are among the first to report pneumonotomies for traumatic injuries of the lungs. Albuerne (1890) reported a case of gunshot wound of the lung which healed by first intention. Hauson and Coe reported a case of gunshot wound of the lung in which septicaemia occurred and was treated by re- section of the rib; recovery follow^ed. Macwatt (1891) re- ported two cases of severe gunshot wound of the lung in which the treatment resulted in recovery. Bickle (1891-92) re- ported a case of gunshot wound of the right lung, and Gonda (1891) had a case of gunshot wound of the lung with fistula remaining. Pinquard (1893) also reported a case of gunshot wound of the lung. Wilson (1897) reported a case where Plate XLIV. X 180. Osteoma. X 180. Dermoid Cyst. (Chapter on Benign Tumors.) GUNSHOT, LACERATED AND INCISED WOUNDS 325 three links of a trace-chain passed through the lung, and Da Costa (1898) reported a case of gunshot wound of the lung. Hermetically closing the chest was suggested by Pare, Larrey, La Motte, and again in 1863 by Dr. Benjamin How- ard, just before the battle of Gettysburg, after which a report of .sixty-seven cases so treated for injured lung is found. Twenty-five recovered and forty-two died. Fifteen out of the forty-two were found upon autopsy not to have received lung injuries. In the absence of statistics, it is safe to say that the same per cent, of those that recovered did not have lung injuries. It is also probable that the same rule could be applied to all chest wounds, viz.: that only about thirty per cent, of undetermined chest wounds do not involve the lungs. Dr. Orpheus Evert (Assistant Surgeon Twenty-second Indiana Volunteers) was among those who sealed chest wounds at Gettysburg, having closed five, with death result- ing in each case. (This incident was communicated personally to the writer.) Only three recoveries took place out of two hundred chest wounds at the battle of Sebastopol, treated by the administration of digitalis, while twenty-seven recoveries ensued in one hundred and twenty-seven wounds of the same character among the English at the same battle, treated by venesection. These reports, like all statistics of this character, while very interesting, do not add much to our knowledge of lung injury, as many of them are injuries of the chest wall alone. It is highly probable that the greater number of recoveries among the English was due to better care and skill, and not to venesection. Then, too, there was a difference in the character of the missile used. About sixty-two and a half per cent, of the wounds re- ceived during the Civil War, United States, 1861-64, were of the chest, while sixty-five and one-half per cent, constituted the combined chest wounds of the French at Sebastopol, the British in the Crimean War, 1855; Italian-French War, 326 THE SURGERY OF THE LUNGS 1859; Austrian-French, 1859. In more recent years the rate has been higher than this, as shown by ]\IcCormac (Sedan), Fischer (Metz), and Beck (Strassburg), during the Franco- Prussian War. The upper lobe was most frequently wounded, the ratio being one to two. Of eight thousand seven hundred and fifteen chest wounds (Civil War, 1861-65), four hun- dred and ninety-two, or five and one-half per cent., spat blood, and sixty per cent, of the total number died. Nelaton (These de Paris, 1880) reports eighty-six cases of chest pene- tration, with twenty-two recoveries, without operation. In twenty cases he resorted to puncture or incision of the chest to remove clots; four died from haemorrhage, without opera- tion. Siege wounds of the chest varied from one to twelve, and one to sixteen, while open field wounds of the chest averaged about one to twenty. These percentages have, perhaps, been increased by im- proved firearms and workmanship. W. C. Borden {Phila- delphia Medical Journal, Vol. VI, No. 7, x\ugust 18, 1900, p. 302) gives the following as a comparative study of gun- shot injuries, both penetrating and non-penetrating wounds of the chest in the Civil and Spanish-American wars. While they show nothing definite as to lung injuries, they are ex- ceedingly interesting. It is to be regretted that more definite statements are not made concerning lung injuries in both private and public practice. Civil War: Non-penetrating. . 11,995 Penetrating 8,269 Spanish-American War: Non-penetrating Penetrating 20,264 61 53 379) ^ 13.921 99 5.373 13 III 870 I. E- — o . 27.85 II. 6 GUNSHOT, LACERATED AND INCISED WOUNDS 327 Ratio of number of recoveries to number of deaths, in war : Recoveries. Deaths. Civil War 6.7 i Franco-Prussian 8.0 i Spanish-American War 14. i i Anglo-Boer War 19.0 i These are the tables to January 27, 1900, by Captain and Assistant Surgeon W. C. Borden, U. S. A., Philadelphia Med- ical Journal, August i8, 1900, p. 302. Table showing the percentage of mortality in penetrating wounds of the chest : Name of Authority. Per cent. French in Crimea English in Crimea French in Italy CiN-il War (U. S.)...._ Prussians in Schleswig Danish in " Germans in Franco-Prussian War. . . Japanese in Chinese War Americans in Spanish-American War. Chenu Matthew Chenu Otis Lofler Lofler Fischer Haga U. S. Gov. 91.6 79.2 46.48 62.66 41.6 67.2 56.7 34-7 24-5 Civil War. Chest Wounds — Total Number. Q hi Undeter- mined re- sults. Per cent. of mor- tality. 11,995 Non-penetrating. . . . 8,265 Penetrating 5.373 487 [8.26 336 f 13.921 870 27.85 Spanish-American War. 61 Non-penetrating 53 Penetrating (114) 13 379 ) ^ 99 2 II. 6 (W. C. Borden, M.D. (Edin.), Captain and Assistant Sur- geon, U. S. A., in the Philadelphia Medical Journal, August 25, 1900, Vol. IV, p. 334.) (For diagnosis and treatment, see under that heading in the chapter on Lacerated and Incised Wounds.) 328 THE SURGERY OF THE LUNGS In Aruvals of Surgery, February, 1901, Dr. E. F. Robin- son, late Acting Assistant Surgeon, U. S. A., gives his ex- perience in treating gunshot wounds in the Phihppines. He says that seventy-eight cases of gunshot wounds of the lungs were brought to his hospital. Of these, ten were dead when they arrived or died within twenty-four hours, leaving sixty- eight cases that were treated. Forty-four of the wounds were caused by Mauser or Krag bullets, twenty-four by Reming- ton or revolver bullets. Five of the forty-four high velocity wounds were infected. Of the twenty-four low velocity wounds, five were infected and died; six others were infected, but having been sent home were lost sight of. He claims that fifty per cent, of the low velocity wounds become in- fected, and only twelve per cent, of the high velocity. He gives one case as a sample; this was one of attempted suicide. The bullet entered the third interspace one-half of an inch to the left of the sternum; the exit was one-half inch ex- ternal to inner border of the scapula. The ball perforated the chest, lung, and probably the pericardium. The patient recovered. Dr. Robinson, in his conclusions, says that the modern gunshot wound (by Mauser, Krag, Lee, etc., rifles) is generally aseptic, and should be treated on this supposi- tion. He claims that the asepsis is due to the character of the bullet and to its high velocity. The explosive effect of the modern high-velocity bullet is not so common as gen- erally supposed. The peculiar effect depends upon the kind of tissue and the velocity. Gunshot wounds were treated by applying an occlusive antiseptic dressing. " The thorax was injured in one hundred and ninety-eight cases, eighty-four non-penetrating and one hundred and thir- teen penetrating wounds. Of the non-penetrating wounds, one proved fatal after an operation for traumatic aneurysm, and one recovered after a ligation of the subclavian artery. Of the penetrating wounds thirty-six cases, or thirty-one and nine-tenths per cent, of the penetrations, were fatal. The bullet I'LATE XLV. X 300. Sarcoma, (Small Round Cell). X 120. Sarcoma, (Small Spindle Cell). (Chapter on Malignant Tumors.) GUNSHOT, LACERATED AND INCISED WOUNDS 329 was removed in one case which ended fatally, and in six cases which recovered. The seventh rib was resected in one case, and the axillary artery was tied in one case with favorable re- sult. "If the penetrating wounds of the thorax reported in 1898 be added to those just mentioned, the fatal cases are found to constitute twenty-seven per cent, of the aggregate. . The aggregate number of deaths, fifty-five, forms twenty-seven per cent, of the aggregate number of cases, one hundred and ninety-eight." (Report of the Surgeon-General, U. S. A., June 30, 1900.) (For Symptoms, Diagnosis, and Treatment, see Chapter on Lacerated and Incised Wounds of the Lung; also Chapter on Foreign Bodies.) BIBLIOGRAPHY Mallet, W., Philadelphia Trans. , London, 1743, XI, 966-968. RiGBY, E., Med. Comment, London, 1790, II, 1-5. Home, E., Trans. Soc. Improv. of Chir. Knowledge, London, 1800, II, 169-173. Key, London Med. Gaz., 1845; n. s., I, 341-343. Campbell, G. W., Brit.-Am. Journ. Med. and Phys. Sc, Montreal, 1846-47, II, 231-234. Moore, E., Lancet, 1847, !> 67-69. Beal, L. B., South. Med. and Surg. Jour., Augusta, 1847, ^- ^•> III, 202. Eve, South. Med. and Surg. Jour., Augusta, 1848. Longmore, T., Lancet, London, 1855, II, 437. Upshur, G. L., Virginia Med. and Surg. Jour., Richmond, 1855, IV, 467. Warren, J. M., Boston Med. and Surg. Jour., 1857, LV, 420. Clapp, H. C, Chicago Med. Jour., 1861, n. s., IV, 73-81. Peters, D. C, Am. Med. Times, New York, i860, I, 327. Sinn, R., Med. Times and Gaz., London, 1861, I, 141. Burge, J. H. H., Med. and Surg. Report., Philadelphia, 1862-63, IX, 100-102. 330 THE SURGERY OF THE LUNGS Farnsworth, p. J., Med. and Surg. Report., Philadelphia, 1865, XIII, 233. RousTAN, A., Bull. Soc. d'Anat., Paris, 1865, XL, 323-326. FoRMENTS, F., South. Jour. Med. Sc, New Orleans, 1866, I, 238, 239. Johnson, W. O., Boston Med. and Surg. Jour., 1867-68, LXXVII, 345- Eve, P. F., Nashville Jour. Med. and Surg., 1867, n. s., II, 225. Woodson, J. B., Kansas City Med. Jour., 1872, II, 274. Wright, D., Med. Gaz., Calcutta, 1873, VIII, 44. Chaplain, E. L., Paris, 1874. Lewis, R. J., Philadelphia Med. Times, 1874-75, V, 294. Crawford, M. H., Virginia Med. Month., Richmond, 1879, VI, 48-50. Albuerne, Cron. Med. Quir. de la Hahana, 1890, XVI, 321-323. Hanson and Coe, Med. Rec, New York, 1891, XL, 536. Macwatt, Brit. Med. Journal, London, 1891, II, 12. BiCKLE, Australas. Med. Gaz., Sydney, 1891-92, XI, 159. Gonda, Gyoaszat, Budapest, 1891, XXXI, 340. Pinquard, Oklahoma Med. Journ., Guthrie, 1893, I, 112-116. Wilson, Fort Wayne Med. Jour., 1897, XVII, 191-193. Da Costa, Ann. Surg., 1898, XXVII, 97-100. LACERATED AND INCISED WOUNDS.— Under this caption are considered all those varieties of lung injury which have not been treated elsewhere. This is in accordance with the classi- fication commonly employed. Historical (1770-1903). — A fellow-officer wounded with General Wolfe at Quebec, 1759, is said to have recovered after the removal of a large portion of the injured lung. (Gould and Pyles's Anomalies and Curiosities of Medicine, Philadelphia, 1 897. ) As early as i yyy, Pew gave an account of a most won- derful recovery after a wound through the lung. Ruddock mentions cases of penetrating wounds of both lungs with re- covery. A paper in the London Medical Times (1844) gives the particulars of a penetrating wound of the right lung with GUNSHOT, LACERATED AND INCISED WOUNDS 33 1 emphysema. Sewell (1849) reported a case of transfixion of the chest of a youth eighteen years old, who accidentally fell on a scythe blade, the point passing under the right axilla, between the third and fourth ribs straight through the chest. There was no haemoptysis, and the patient soon recovered. Core (1859) reported a case of laceration of the lung and collapse of the organ without fracture of the ribs. In the Sydenham Society Transactions (i860) appears Casper's re- port (pp. 1-165) of two cases of wound of the lung ; in one case a carriage pole and in the other the end of a mast passed through the lung. Both cases recovered. Finnell (1861) had a caseof a man struck by an iron bar. It penetrated the thorax three inches into the floor, having entered posteriorly between the ninth and tenth ribs of the left side, coming out anteriorly be- tween the fifth and sixth ribs. There was but slight constitu- tional disturbance, the man soon recovered. Chicon treated a wound of the lung, where there was much purulent matter, by thoracentesis. Adams (1867) reported a case of penetrating wound of the right lung with external em- physema. Longmore ( 1871 ) gives a case where a lance trans- fixed the right side of the chest and lung; the soldier recovered. Rivington (1871) reported an interesting case of an incised wound of the shoulder and chest; the lung was penetrated. There was paralysis agitans, apparently hereditary; recovery ensued. Pozzi (1873) reported a complicated case of wound of the lung; there was no haemoptysis, but ossiform concretions formed, simulating fracture of the ribs. There was also sup- puration of the pericardium, resulting in death. De Morgan ( 1874) reported a case of penetrating wound of the chest with an iron rail, with laceration of the lung and death. Richards (1875) reported a wound of the lung with recov- ery, and (1880) an equally interesting case of recovery from a penetrating wound of the thorax with immediate pneumocele, requiring excision of a portion of the lung. Brown reports a case of a boy, who, while running to a fire, struck the point of 332 THE SURGERY OF THE LUNGS a carriage shaft, which passed through the left chest below the nipple. There was no haemorrhage; the boy recovered. In- glott (1890) reported a case of wound of the right lung, fol- lowed by immediate recovery. Brokaw reported the case of a shipping-clerk, who received a thoracic wound, extending from the third rib to within one inch of the navel, thirteen and one-half inches long, completely severing all the muscular and cartilaginous structures. In addition, there was a terrible abdominal wound, causing almost complete intestinal evisceration. The lung partially collapsed. The cartilages were ligated with heavy silk, and haemorrhage checked by ligature and by packing gauze in the interchondral spaces. The patient was discharged in a little over a month, the only evil result remaining being a small ventral hernia. Sadler (1891) reported a case of stab wound of the lung. Montel ( 1891 ) reported a lung wound and Reading ( 1891 ) re- ported a case of perforating wound of the right lung wit-h re- covery. Hodenpyl (1893) reported a perforating w^ound and Alexander (1893) had a case of a stab wound of the lung. Lopez (1894) reported a recovery in a case of penetrating w^ound caused by a sword. Pyle (1894) reported a case of a boy who had been run over by a hose-cart. There were no signs of external injury and no fracture of the ribs. There was marked emphysema ; the neck and side of face were greatly swollen by the extravasated air ; the tissues of arm were also infiltrated with air ; consciousness was never lost. On the eighth day, the temperature was nor- mal. The boy left the hospital apparently well, without evi- dence of pulmonary embarrassment. He developed diaphrag- matic breathing which seemed fully sufficient. In the Annals of Universal Medical Science (1872), there appeared an extraordinary case of a boy, fifteen years of age, 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 Plate XLVI. X 110. Sarcoma, (Giant Cell). X 70. Carcinoma, (Epithelial). (Chapter on Malignant Tumors.) GUNSHOT, LACERATED AND INCISED WOUNDS 333 the chest ab'out eight inches long. The third, fourth, fifth and sixth ribs were fractured and torn apart, and about an inch of the fourth rib was lost. Several jagged fragments were re- moved. A portion of the pleura, two by four inches, had been torn away, exposing the pericardium and the left lung, 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 patient finally recovered, without lateral curvature. There is an Indian report of penetrating wound of the lung by Roy (1895). Gazotti (1897) also reported his operation for a traumatic injury of the lung. Tunnin (1897-98) wrote on surgical intervention in grave injuries of the lung, and also on lung surgery in general. Hadra (1898) indorses pneu- monotomy, as does Doyen (1898) in an article on surgery of the lungs. Tait (1898) uses the word " pneumonotomy " in reporting a case. In 1894 the author had a patient, who, in 1887 had been stabbed with a knife. The wound, three inches long, extended through the intercostal space. Six ribs were resected and the lung was found atrophied to the size of a man's fist. No normal lung tissue remained. Patient was in excellent condi- tion April I, 1903. In 1869 G. R. Ricketts was called to treat a man who had been thrown on a circular saw. It was found that all the ribs on the right side had been divided, within two inches of the spinal column. The scapula was divided also. The teeth of the saw penetrated the lung itself, severing the second branch of the right bronchus. The wound was cleaned of debris (part of the man's shirt had been forced into the thoracic cavity) , and closed with sixty-nine sutures. In spite of infection, which occurred, the man recovered. He is alive and well thirty- four years after the accident. Only penetrating wounds and injuries of the chest wall in- volving the continuity of the lung are herein considered. All 334 THE SURGERY OF THE LUNGS other wounds of the chest wall have been disregarded. Re- search work to determine what can, and what cannot be done with the lung, has been slight in comparison with the work done on other organs of the body. However, enough has been ac- complished to establish many important facts. The surgery involved in this class of cases is, perhaps, more interesting, al- though less frequent, than tuberculous abcesses. More hope, however, can be given. In one, a chronic condition, which has become desperate and hopeless, is encountered, while in the other, a healthy subject is usually the victim. Of rupture, gunshot wounds, and injury to lung from lacer- ation, haemorrhage is one of the most important symptoms. It may be rapid or slow, primary or secondary, or it may be latent from any of the thoracic or pulmonary vessels. If haemorrhage be latent, it may in most cases be from the thoracic or pulmo- nary vessels. If the haemorrhage be external, the intercostal or internal mammary, or both, are injured. The signs of lung bleeding are dyspnoea, rapid and difficult breathing, am- phoric sound, metallic tinkling, faintness, pale, livid lips, pain, cough, cold sweat, vomiting, anxiety, oppressed circu- lation, engorgement of lung, dusky countenance, and hard pulse. Air in wound or the expectoration of froth may confuse diagnosis. Blood may escape from the lobe into the pleural cavity, and thence through the chest wound, bronchus, or mouth, into the pericardial or mediastinal space, the oesophagus, or into the peritoneal cavity. Each or all of these conditions may exist at one and the same time. When the haemorrhage is intrathoracic there is frequently haemoptysis. This may be distinguished by the presence of rales in the bronchi of the affected lung, history of injury, etc. Ha^mopericardium causes an increase in the area of cardiac dul- ness and interferes with the heart's action. Hcemomediastinum produces physical signs similar to those of abscess. If hcnemo- thorax or pneumothorax be present without hcemoptysis the GUNSHOT, LACERATED AND INCISED WOUNDS 335 lung is intact, and, usually, the bleeding parietal. Hsemoperi- cardium is not always proof of injury to the heart itself. If there is haemoptysis, there are more rales in the injured lung than in the sound one. One of the curious facts noticed by ancient writers was the amelioration of the symptoms caused by thoracic wounds after haemorrhage from other locations, and naturally in the treat- ment of such injuries, this circumstance was used in advocacy of depletion. (Gould and Pyle, 1897.) Haemoptysis may be due to a blow upon a pathologic lung where cysts, abscess, tumors, etc., are present, and may, there- fore, be confusing. It may also come from the trachea, nose, or mouth. The patient may not spit or cough blood in severe lac- eration of the lung, especially, in gunshot or penetrating wounds, other than that from a knife or sharp-pointed instru- ment. Contusion may cause emphysema, and it is always more or less present in the lung to which it is confined, unless the parietal pleura is lacerated, in which case the emphysema may extend to the chest wall and become local or general. Sub- cutaneous emphysema rarely occurs after a rupture of the lung, unless there is pneumothorax. Pneumothorax, haemothorax, pleurisy with or without effusion, rupture of lung or diaphragm, may appear alone or together soon after injury. Emphysema and pneumothorax are of little importance, especially the latter. Percussion is of little or any value if air is in the pleural cavity, or a large bronchus be severed, in which case, the lobe which it supplies would be retracted upon itself. Senn claims that a rise in temperature during the first forty- eight hours is no indication of the existence of sepsis, as with few exceptions, it indicates a febrile disturbance, caused by the absorption of fibrin ferment, the so-called " fermentation fever." He also claims " That rest in the recumbent position, with the chest slightly elevated, is essential in aiding spontane- ous arrest of haemorrhage, and in preventing complications." (Journal American Medical Association, July 9, 1898.) 336 THE SURGERY OF THE LUNGS Others claim that in cases where there is fluid in the pleural cavity a rise in temperature indicates infection. When the laceration of the lung is extensive, there is im- mediate haemorrhage into the bronchi, and haemoptysis, imme- diate and copious. There is severe shock and collapse, thready pulse, labored and irregular breathing, and subnormal temper- ature. Physical examination reveals evidence of pneumotho- rax. The first twenty-four hours are full of danger. The patient may die of shock, loss of blood, or by drowning in his own blood. After the shock has passed away, the case is that of pneumothorax with a tendency to secondary inflammation of the lung and pleura. If the injury be kept free from infec- tion, and, if there is no large haematoma, recovery will take place in a few days. The prognosis depends on the reaction of the vital forces of the patient. But it must be remembered that where there is a large external wound, there is danger from external haemor- rhage and sepsis, as well as from internal haemorrhage and sep- sis. In such a case there may be traumatopnoea instead of em- physema. When the lung has been injured, whether the wound be a simple rupture or laceration of the lung, there is often injury to the mediastinal and thoracic vessels. In such cases, if the great vessels are injured, immediate and fatal haemorrhage re- sults. There may be later complications, such as aneurysm and mediastinal abscess. In case of injury to the thoracic duct, it is said to heal if the duct is not completely divided. Thorough examination should be made of the mediastinal space. If clots be present, they must be removed, incising the chest wall if necessary. Treatment — Venesection is especially desirable when as- phyxia is present ; it will relieve dyspnoea, as shown by actual experiment. Although it has been stated that about one in ten cases of lung injuries should be venesected, none has as yet been reported treated in this way. GUNSHOT, LACERATED AND INCISED WOUNDS 337 Dissect bronchus and ligate, using small needle with kan- garoo tendon. Dissect out all bleeding vessels, ligate and pack with gauze. Adhesions are greater in the aged. Take tempera- ture before and after in axilla. Catgut, unless chromicised, should not be used in lung surgery. Air must be excluded from chest, which necessitates complete closure of bronchi, which is difficult with ligature. Palpate lung with the finger. Small balls from small-bore guns are more likely to lodge in the lungs. Such cases are more favorable, as the bullets are more likely to become encysted. Mortality is higher when bul- lets pass through the chest from side to side, or at the base of a lobe. But the nearer the diaphragm the w^ound may be, the more favorably is it situated for drainage, and the more favor- able is the prognosis. The care of wounds of the lung, whether gunshot, incised, or lacerated, has been the subject of great controversy. Dr. Antona recommends in rupture of the lung to provoke cough- ing, compressing the sound lung at the same time, which causes the diseased lung to bulge out through the wound, and prevents pneumothorax. (Surgery of the Lung, Journal American Medical Association, January i6, 1898, p. 169, col. xxx.) Do not move or examine the patient ; never place the patient erect, nor percuss, or cause deep inspiration, or expiration. Pre- vent coughing by giving codeia, or morphine if necessary. Watch color of skin, expression of face, and pulse. Determine, if possible before operating, whether or not the diaphragm is injured, as it may be necessary to open both the thoracic and abdominal cavities. Gunshot wounds, sometimes simulate those from a knife. The mortality is about sixty per cent, on the field of battle. Dupuytren, Pirigoff, Gross, Erichsen, and others used the probe. Daunne, Legonest and the more modern writers do not use the probe or finger. Dessault, Richter and B. Bell raised serious objections, and Foulmart opposed sounding in all cases of penetrating wounds. The external wound should never be 338 THE SURGERY OF THE LUNGS hermetically sealed, as suggested by Howard. Deunne says, "Examine the chest," old masters say not to do so. This is a matter of judgment on the part of the surgeon. Wound of the diaphragm should not, however, prevent the adoption of surgical measures. {Journal American Medical Association, Vol. XXX, p. 140, Vol. XXIX, p. 1207.) The treatment of haemorrhage is of great importance in this connection. To stop haemorrhage from the great vessels, all that can be done is to keep the patient absolutely quiet, using morphine liberally, and possibly gelatine in one per cent, solu- tion hypodermically or in the rectum. For haemorrhage from the lung the expectant course is ad- vocated by most surgeons, although some say to cut down upon and pack the visceral wound. If nothing is done, the lung will bleed until it has completely retracted ; that is, if there be no ad- hesions, and if the pleura be not full of blood. Some writers favor " splinting " the lung by the injection of air into the pleura. One prominent writer ixiakes the as- tounding assertion that " clotting " seems not to occur in the pleura of man. But experiments and observation prove that this statement is untrue. The blood does clot in the pleura as in any other part of the body. In case of laceration of the lung, where there is a large ex- ternal wound, local therapeusis is required to prevent external haemorrhage and sepsis. The wound of the thoracic walls should be treated as an ordinary surgical wound. Endeavor to obtain asepsis by removing foreign bodies and by copious irrigation with sterile solutions. Pressure or ligature, will se- cure haemostasis. Do not allow any of the solution that is used to get into the pleural cavity. Only simple aseptic, and not antiseptic, solutions should be used; so that if any part of the solution does get into the pleural cavity, it will do as little harm as possible. Bandaging with adhesive plaster, muslin, or plaster of Paris, in an attempt at fixation of the chest to place the lung at rest Plate XLVII. ^ Ww^- :><- X 1000. Bacillus Anthracis, (Spores). A • \ / 't- \ \ X 1(10(1. Bacillus Amrogexks Capsulatus. (Chapter on Bacilli.) GUNSHOT, LACERATED AND INCISED WOUNDS 339 is useless, for it cannot be clone. The lung when inflated, presses upon the chest wall equally in all directions so that if the bony chest could be prevented from expanding in any of its diameters, the diaphragm would give compensation. The lung cannot be put at perfect ease even when the chest wall is open, for even then there is slight motion. (See chapters on Foreign Bodies, Surgery of the Lungs, and Gunshot Wounds.) BIBLIOGRAPHY Pew, R., Med. and Phil. Comm., London, 1777, V, 188-190. Bell, R., Med. Comm., London, 1787, decade 2, 1, 349-352. Ruddock, Prov. Med. and Surg. Jour., London, 1842. Med. Times, London, 1844, X, 551. Sewell, Am. Jour. Med. Sc, Philadelphia, 1849. Skinner, J. A., West. Lancet, San Francisco, 1852, XIII, 468-470. Ferrari, Raccog. Medico di Fan., 1^855. Core, W. R., Dublin Med. Press. 1859, XLI, 194. Finnell, Med. Times, New York, 1861, II, 304. HoYLAND, London Med. Record, 1863, II, 241. Chicon, Gaz. d. Hdp., Paris, 1865, XXXVIII, 394. Adams, J., Lancet, London, 1867, II, 665. Longmore, Lancet, London, 1871, I, 78. RiviNGTON, Med. Press and Circ, London, 1871, XI, 3. Pozzi, S., Bull. Soc. d'Anat. de Paris, 1873, XLVIII, 749-753. De Morgan, C., Lancet, London, 1874, I, 90. Richards, V., Indian Med. Gaz., Calcutta, 1875, X» 213. Brown, Trans. Med. Soc. Pennsylvania, 1877, pt. 2, 730. Richards, Indian Med. Gaz., Calcutta, 1880, XV, 213. Inglott, Brit. Med. Journal, London, 1890, I, 75. Brokaw, St. Louis Courier of Med., etc., 1890. Sadlier, New York Med. Jour., 1891, LIV, 266. Montel, Gazz. d. Osp., Napoli, 1891, XII, 592. Reading, Med. News, Philadelphia, 1892, LX, 156. 340 THE SURGERY OF THE LUNGS HoDENP\x, Med. Rec, New York, 1893, XLIII, 535. Alexander, Jour. Med. and Surg., 1893, LXXIII, 247. Lopez, Encyclopedia, Barcelona, 1894, VII, 37-46. Pyle, Med. News, Philadelphia, Feb., 1894. Roy, Indian Lamet, Calcutta, 1895, VI, 305. RiCKETTS, B. M., Cincinnati Lancet and Clinic, 1896, p. 237. G.\Z0TTi, Gazz. d. Osp., Milano, 1897, XVIII, 1063. Fixkelstein, B. K., Stab wounds of Thorax. Bertolucci, p., Corriere San Milano, 1900. Le Boutillier, W. G., Annals of surger}% Philadelphia, 1902, XXXV, 553-573. Cerne, Normandie Med., Rouen, 1902, XVIII, 200. CHAPTER VII FOREIGN BODIES Foreign bodies in the lung or bronchi may be removed by- coughing, and may escape through the chest wall into the trachea, oesophagus, or through the diaphragm, and from the subcutaneous tissue at almost any point upon the body. Small foreign bodies, such as bird-shot, may become encysted in the lung and remain harmless, while others may gravitate, from their excessive weight, through the entire lobe and drop into the pleural cavity, to cause subsequent serious trouble. Foreign bodies may enter the chest cavity, and only the chest wall be injured. Their course depends upon the angle described by the missile. Experiments with the x ray show that the position of a foreign body in the lung, when expanded, is changed when the chest is opened and the lung contracts. The foreign body may not be in the bronchus but in the lung tissue. Historical (1671-1903). — Buchtfield (1671-72) was among the earliest writers who published anything with reference to foreign bodies in the lungs. Tillingius (1688) refers to cal- culi having been expelled from the lungs. Kirby (1700) wrote on the same subject and Arnot ( 1742) published cases of bone having been removed by coughing. De Carendeffez (1803) gave an analytical description of certain stony concretions coughed up from the lungs ; Valentine (1807) reported his observations on stony concretions expec- torated by a phthisical patient; Gilroy (1831) reported a case of pulmonary abscess caused by the lodgement of a chicken- 341 342 THE SURGERY OF THE LUNGS bone in one of the bronchi. Graham-Craig (1834) reported a case of the deposit of charcoal in the lungs of a miner {anthra- cosis). Brigham ( 1838) published a case in which a brass nail was found in the lung; Burford (1838) reported cases of con- cretions in the lungs. Judd (1838) reported on calcareous and bone-like concretions, and Barker (1842) reported a case of foreign body in the lung. Maikeller ( 1846) reported a case of black phthisis, or ulcer- ation, induced by carbonaceous accumulations in the lungs of coal miners. There are numerous reports of cases of bones, and various kinds of foreign bodies having been expelled from the lungs, one of which is that of Struthers (1852), where a foreign body was in the bronchus for four and one-half years. The case terminated fatally by gangrene. Wales ( 1854) reported a case of bronchitis occurring in the person of a muslin gassurger in whom the expectoration was so charged with charcoal as to resemble that of pneumonia. Hamilton (1854) contributes to the literature of the expec- toration of calcareous bodies. The calcareous bodies are formed in the pulmonary veins and are about the size of bird- shot and yellowish-white in color. They are composed of car- bonate or phosphate of lime. Emison ( 1856) had a case in which a bullet was expelled by coughing, two weeks after it had entered the thorax. Leach gave a case in which a bullet was impacted in the chest for forty-two years. Hamilton ( 1858) reported a case in which he removed a knife from the left pleural cavity by the exsection of the sixth rib, and the introduction of the hand. Bristowe (1857) reported a case of a foreign body in the lung. Evan (1861) gave an account of a case of abscess of the lung from the presence of a foreign body, which was evacuated through the bronchial tubes and through the thoracic walls ; the patient recovered. There seems to be no way by which small foreign bodies, such as coal deposits, can be removed from the pulmonary Plate XLVIII. Bacillus Friedlander_, (Acute Croupous Pneumonia), (Copied from another publication.) X Co. Pneumonia^ (Human Lung), 222-4. Reynaud, Marseilles Med., 1897, XXXIV, 581-586. Clark, British Medical Journal, London, 1897, ^^y 800-802. Edwards, Lancet, London, 1897, II, 1585. MiTTHEiL, De Med. und Chir., Bd. I, H. L., also Goidd's Year- Book, 1897, P- 115- Northrop, Medical and Surgical Report, Presby. Hasp., New York, 1897, II. 83-89. Crespin, Bull, et Mem. Societe Med. d. Hop., Paris, 1897, XIV, 734-736. Kijens I, Gaj^. leg. Warnaawa, 1897, XVIII, I, 32, 64, 102. Moore, British Medical Journal, London, 1897, II, 342. SiCARD, Bidl. Societe d' Anatomic, Paris, 1897, LXXII, 427- 431- ABSCESS— BRONCHIECTASIS 373 MoRELLi^ Morgagni, Milano, 1898, XI, 669-681. WiTHiNTON, Boston Medical and Surgical Journal, 1898, CXXXVIII, 220-225 ; Disc, 231-253. Burgess^ Lancet, London, 1898, I, 1054. KaRj Indian Medical Record, Calcutta, 3, 457. Halstead, Detroit, 1898, IV, 524-569. Mariani, Rcviczv d. Med. y CJiir. Prac, Madrid, 1898, XLIII, 361-368. Glazebrook, Nat. Med. Review, Washington, 1898-99, VIII, 428. Alexseyeff, Diesk. Med., Moskau, III, 405-408. Schmidt, Z)(?w^. Med. Wochenschr., 1898, 1503-45. HoBART, Wien. Klin. Wochenschr., 1898, 1083. Lewis, Philadelphia Medical Journal, 1898, II, 1368. GooDLEE, British Medical Journal, 1899, I, 133-7. Ktos, Tidschr. f. d. Morske, Kristiana, 1899, XIX, 15-23. Elsner, Medical Nezvs, New York, 1899, XLIII, 150-165. Morton, C. A., British Medical Journal, London, 1900; I, 379- 380. Cackovic, Liecnciki Viesnik. Zagreb., 1900, XXII, 54. Jacobson, O., Ztschr. f. klin. Med., Berlin, 1900, XL, 294-330. Parascandolo, Gior. Interna^, di Sc. Med., Napoli, 1900, XXII, 529. Laub, Allg. Wien. Med. Ztg., 1901, XLVI, 326-328, 338-339- ScHULZ, J., Centralb. f. d. Grenzgeh. d. Med. u. Chir., Jena, 1901, IV, i-io, 65-71, 97-104, 145-158. Wills, Le Moyne, Journal American Medical Association, 1901, XXXVI, 19-22. Watkins-Pitchford, W., British Medical Journal, London, I 955-956. Mathew, G. p., British Medical Journal, London, 1901, I, 888-889. Lange, K., Hygeia, Stockholm, 1902, LXIV, 372. Lawrence, F. M., Hahnemann Month., Philadelphia, 1902, XXXVII, 1 19-123. 374 THE SURGERY OF THE LUNGS Putnam, Medical Nczvs, New York, September 13, 1902. Schooler, Iowa Medical Journal, Des Moines, Iowa, July 19, 1902, p. 370. Whitacre, H. J., Journal of the American Medical Associa- tion, September 27, 1902. CHAPTER IX GANGRENE Gangrene of the lung, while not infrequent, has been dealt with rather mildly. It is either circumscribed or dif- fuse, and has a downward course which can reasonably be ascribed to the course of the lymphatics of the lung as they terminate in the bronchial glands at its root. Perhaps this downward course is due to the lessening of the vitality of the pulmonary tissue as the extreme border of the apices is approached. The site is most frequently the posterior aspect of the upper portion of the lower lobe. Learee says gangrene of the lung is more frequent in the lower than in the upper lobe. It has been shown that women have gangrene less frequently than men. Its bacillus resembles that of anthrax (Pasteur and Koch) , and it will not grow unless oxygen (?) is excluded ; hence its favorite location is within the chest. Experiments have shown that one attack gives immunity, and that the injection of toxines will also immunize. Etiology. — The causes of gangrene are numerous ; such as syphilis, abscess from any cause, foreign body, and the acute inflammatory diseases of the respiratory system. It is occasionally the result of the pressure of aneurysmal, or other intrathoracic tumors, on the blood-vessels. Fountain enumerated among the causative factors traumatic injuries, embolism, and immersion of the body in cold water. Foun- tain's case as reported, was gangrene of the lung resulting from a foreign body lodged in the right bronchial tube, and terminating in emphysema, and perforation through the 375 376 THE SURGERY OF THE LUNGS diaphragm into the colon. Trauma, infarct, diabetes, and, in cases of dementia and epilepsy, food in the trachea, are also some of the causes of gangrene of the lung. This may explain the fact that the statistics of Fischel and others show that gangrene of the lungs occurs more often among the insane. Historical (i 858-1 903). — Martin (1840) reported an inter- esting case of abscess of the peritonaeum opening into the bronchi, causing gangrene of the lung. Fuller (1859) re- ported a case where aneurysm of the thoracic aorta had pro- duced gangrene of the upper lobe of the left lung, and had terminated by bursting through the pericardium. Baretz (1874) reports a case of gangrene of the lung from consecu- tive embolism. Magrath (1880) reported a case of gangrene of the right lung with caries of the spinal column, from the passage of a spear of grass into the bronchus. However, of all causes, pneumonia is the most frequent. Holt (1885) had a case of a child three years old in which gangrene of the lung followed an attack of primary pleuro- pneumonia. Andree found in five hundred and eighty-three autopsies of pneumonic subjects that thirty-two per cent, had gangrene. Huss found but twelve per cent, in two thousand one hundred and sixty-six cases of pneumonia in men from thirty-five to fifty-five years of age. No doubt the percentage of gangrenous cases in pneu- monic conditions is greatly increased in childhood and old age. There is a certain percentage of lung gangrene, fol- lowing pneumonia and other diseases, which, no doubt, re- cover by the formation of an abscess, and drainage in the various ways the abscess develops. The mortality of gangrene of the lung from various causes, if let alone, is probably eighty-five or ninety per cent., while those that recover by operative measures are tabulated by True, Hufinaker, and Heydweiller (1879-92), to be in the proportion of thirty-six recoveries to thirty-one deaths. Plate LIV. ^v^-' X 30. ECHINOCOCCUS. X 9. Paragonimus Westermani. (Chapter on Animal Parasites.^ GANGRENE 377 Many interesting facts may be deduced from the re- ports of surgeons in regard to gangrene of the lungs, and notably from operations. Guerin (1830) originated a per- cutaneous method which was revived by Vidal (1882). Breschet (1831), MacLeod (1836), Cleassens (1839), Hast- ings and Stork (1844), Herff (1844), and Collier (1855), operated evidently for empyema. Finny (1844) operated too late for gangrene and death resulted. Smith (1883) reports an operation for gangrene, while Rose (1884) was probably the first to institute extensive surgical measures for gangrene of the lung. Smith (1880) had previously treated pulmonary gangrene by incision. White and also Neisler (1872) opened a tuberculous cavity of the lung. Peterson reports a case of gangrene of the lung, with rupture of the eroded vessels, and sudden death from haemorrhage into the pleural sac. Fenger (1884) wrote on the surgical treatment of gangrene of the lung, in a report which is of much value. Cayley and Gould's case of gangrene of the lung (1883) recovered. Run- neberg (1887) operated for gangrene. Trzebicki (September, 1892) collected twenty- four cases operated upon. There were seven complete cures, one case of fistula, one not healed; in two cases the results were not known; thirteen deaths resulted. True has tabulated most of the cases to 1885, and Paget from 1885 to 1895. Simpson (1890) reported four cases of haemorrhage into the lung tissue with oedema; he treated by aspiration, but the patient died. Anthony had a case re- quiring amputation of the lung; he does not state the cause, but it is probable that it was not for cancer. Lebert, Hutch- inson, and Bonome have collected the cases where operations were performed for gangrene of the lung. Out of seventy- one cases operated upon, fifty-four died, or sixty-two and a half per cent. True lost six out of thirteen; Richevalle, fourteen out of thirty-one; Pabrecauts, ten out of twenty-six, and Paget, 378 THE SURGERY OF THE LUNGS two out of thirteen, which brings the mortahty down to thirty-nine per cent. Thus, it is shown that twenty-three per cent, more recover with operation than without it. From reports of competent surgeons, it is probably only traumatic gangrene that offers anything to surgery, except drainage. McFarland had a case of gangrene of the lung that re- sulted fatally. Hofmokl (1889) reported a case of lung gan- grene. Kiemann reported a case of induration of the lung with bronchiectasis. Ross (1889) published a case of pneu- monomycosis with abscess of the lung, followed by gangrene. He made a demonstration of fungus and bacteria. Hisch- lerd and Terray (1889) reported on the causes of gangrene of the lungs. Girode (1889) had a case of gangrene of the superior lobe of the left lung, complicated by tuberculosis and old heart troubles. Soupoult (1889) reported a very interesting case of a large gangrenous cavity in the lung, which gave all the signs of pyopneumothorax caused by a suppurating hydatid cyst. Martin (1890) offered suggestions on the treatment of pulmonary gangrene, and Jaccoud, Masci, Standthartner, and Ebstein (1890), have reports on this important subject. Schrotter's work on the aetiology of pulmonary gangrene, etc., contains valuable hints. Mader also has some ideas as to the treatment of this disease. Laporte had a case of pul- monary gangrene in a man who was a porter, in which the two valves of the pulmonary artery adhered. Bastianelli (1889-90) employed pneumonotomy in treat- ing pulmonary gangrene. Hewelke (1891) too, has some useful hints on lung therapy. O'Gorman (1891) reported his notes on cases of circumscribed pulmonary gangrene and fetid bronchitis, with pathology and treatment. Florschutz (1891) showed the connection between pulmonary gangrene and diphtheria. Bull (1891) reported two cases of gangrene of the lung, operated upon. Thue (1891) also reported a GANGRENE 379 case of gangrene of the lung operated upon with subsequent death, as a result of pericarditis. Monsd (1892) described pneumonotomy in connection with a case of gangrene. Dunn (1892) reported a case of softening of the sensory tract of the internal capsule with lesion, apparently trophic, on opposite side of the body; death ensued from gangrene of the lungs and pulmonary haemorrhage. De Ceronville (1892) published his observations on two cases, in which he resorted to pneumonotomy for gangrene of the lung. Delageniere employed partial pneumonotomy in similar cases, and Wells also reports cases, Streng pub- lished a paper on infusoria in the sputum, as a means of diagnosis. Lop writes on the aetiology of pulmonary gan- grene, and Moussons on its surgical treatment, Fedotofif and Simonin each add to the number of cases reported. Goelet had a case of gangrene of the lung following an attack of pleuro-pneumonia. Reimbach has something to say about etiology of lung gangrene, Hofmokl (1895) re- ported a case in which he resorted to pneumonotomy, with death of patient, Mader and Parmerter follow with reports. Babes (1895) published his "Pathogenesis of Pulmonary Gangrene," and Mery gave the results of his bacteriological studies. Alexsleyeff, who apparently finds so much fascina- tion in the study of the lungs, has a valuable paper also on the same subject. Roscins (Gould and Pyle's " Anomalies," et caetera, Phila- delphia, 1897) is said to have removed successfully the pro- truding and gangrenous portion of a lung which extended through a penetrating wound of the chest wall. Vekonet (1897) reported a case of lung gangrene surgi- cally treated. Ewart (1897) has a paper on his methods of incision and drainage. Within the last two or three years many surgeons have given their time and attention to the treatment of gangrene of the lungs. 380 THE SURGERY OF THE LUNGS The greater number have devoted themselves to the surgery' of the disease. In addition to those already referred to, readers interested in this subject might profitably con- sult Skeda, Patton, Rendu, Zalenski, ViUiere (1898), who advocate surgical intervention in treating pulmonary gan- grene. Besson reports a death from haemoptysis. Feme, Swan, Bramwell, Fussell, and Robertson have reported cases. Dere- reaux (1899) describes his method of treatment with creosote. Warrack (1899) reported a case of a tooth impacted in the left bronchus, causing gangrene. Pique published a valua- ble paper on the curable forms of the disease. H. Lenhartz reports twenty-three cases of gangrene of the lung, treated by resection of ribs and pneumonotomy. There has been complete and permanent recovery in eleven; three have died since from tuberculosis, three from sepsis, and one from general debility. Lenhartz operated in two sittings, as it is impossible to suture the pleura, and union has to be accomplished by vigorous compression. He warns against explorator}' puncture, as it entailed empyema in at least one of his cases. {Journal American Medical Association, March 22, 1902, p. 799, Vol. 38, No. 12.) Pathology — There are two forms of pulmonary gangrene, circumscribed and diffuse, or the two may be combined. In the circumscribed the area is first brown and dry, with hurry- ing congestion, and blood infiltration; there is also periodic or constant haemorrhage from eroded vessels. Extension of the process is probably due to gravitation of fluid into the ends of the bronchi, combined with the low vascularity of the periphery of the lung. Symptoms and Diagnosis. — The chief point in the diagnosis of pulmonary gangrene is the odor of the sputum. When placed in a glass, the sputum will separate into three layers. The upper layer will be found mucopurulent and frothy ; the middle greasy and watery ; and the bottom layer will con- Plate LV. II' Paragoniimus WESTEiniANi (from lungs of a hog). I. Section Containing the Lung Fluke Cyst Cut Open. 2. Lung Flukes, Natural Size. 3. Con- tents of Cyst Containing Eggs of Lung Fluke, Greatly Magnified. (Chapter on Animal Parasites.) GANGRENE 381 *sist of pus and yellow shreds of tissue, which, with the peculiar fetid odor, is diagnostic. Multiple cavities from lung abscess or gangrene are espe- cially hazardous. The temperature may be above (105°) or below the normal (97°). The pulse is rapid and feeble, the skin dusky. There are prostration and an anxious expression ; there is dulness upon percussion over the affected side, and rales can be heard in the otherwise consolidated lung. The respira- tory murmur may be wanting, and, perhaps, exaggerated resonance. The symptoms in fact simulate those of pneu- monia in the stage of consolidation. Fragments and pus may escape through the bronchi and mouth. In addition to the high fever, prostration, offensive breath, rusty sputum, there is a chill at onset, adynamia, dyspnoea, cough at first, more or less pain ; the temperature is subnormal in the later stages. The expectoration may amount to twenty ounces in twenty- four hours, and its marked gangrenous odor is characteristic and never to be mistaken. Leyden says the patient reclines toward the affected side. Treatment. — Open chest posteriorly by resecting two or more ribs, preferably the fifth or sixth, or both. If possible, operate rapidly with a local anaesthetic. Insert a finger for exploration and evacuation of pus, or debris, or both. Do not pack the cavity with gauze, unless for haemorrhage, but keep the chest wall freely open for drainage and irrigation. All bleeding vessels in the thoracic wall must be occluded, as the severing of each tissue is accompHshed. It is necessary in all operations for gangrene in the upper portion of the lung to open the pleural cavity at its lowest point, that drainage may be accomplished by gravity. If possible, the gangrenous portion should be brought out of the chest opening. If the entire lobe be involved, three ligatures of silk or kangaroo tendon should be used to transfix its base, one to surround the vessels, one the bronchus, and one around the lung tissue proper. This once accomplished. 382 THE SURGERY OF THE LUNGS the lobe should be cut away, as in gangrene or any other tissue. Complete excision and drainage are the two great princi- ples involved in operating for gangrene of the lung. Stimu- lation and nourishment should receive careful attention. Much of the operative work will, no doubt, be done without general anaesthesia. The surgeon's finger should be used instead of the needle or knife. None of the important blood- vessels will be severed, and none of the bronchi injured, if the finger be thrust through the pleura and lung tissue. The sense of touch will enable the operator to locate the abscess with greater exactness. The finger can as easily detect pus by palpation in the lung as in any other soft structure of the body. Garre reports one hundred and twenty-two cases of gan- grene of the lung operated upon, with sixty-six per cent, cured. August 3, 1903. Dear Doctor Ricketts: In June I operated on a young lady suffering with gangrene of the lung. Opening was made over second and third ribs, anteriorly, on right side of chest. Patient died on the operating table after one rib had been re- moved. The gangrene followed extraction of teeth — chloro- form and ether being used — very likely followed by an aspir- ation pneumonia. Autopsy showed gangrenous area with abscess directly under second, third, and fourth ribs. O. A. Blumenthal. GANGRENE 383 BIBLIOGRAPHY Martin, Medical Examiner, Philadelphia, 1840, III, 349-352. Fountain, North Amer. Med.-Chir. Rev., Philadelphia, 1858, III, 854-862. Fuller, Transactions Path. Soc, London, 1859-60, XI, 62- 64. Learee, Lancet, London, 1871, II, 47. Barety, Compt. Rend. Soc. de Biol, Paris, 1872 (1874-75), iv,pt. 2, 145-156. Magrath, Lancet, London, 1880, I, 89. Rose, International Sc. Rec, New York, 1880-81, 7. Smith, Lancet, London, 1880, I, 86-88. Peterson, Buffalo Med. and Surg. Journal, 1883-84, XXIII, 219. Fenger, Transactions Illinois Med. Soc, Chicago, 1884, III, 62-68. Gould, Med.-Chir. Transactions, London, 1884, XLIV, 209- 215. Holt, Arch. Pcediat., Philadelphia, 1885, II, 88-95. Runneberg, Deutsche Arch, fiir Klin. Med., 1887, Bd. XLI, p. 91. McFarland, Proc. Path. Soc, Philadelphia, 1888-89, II, 66. HoFMOKL, Berlin d. k. k. Krankenaut Riidolph-Siftung, Wien (1888), 1889, p. 350. Kiemann, Berlin d. k. k. Krankenaut Rudolph-Siftung, Wien (1888), 1889, pp. 355, 356. Ross, Australia Medical Journal, Melbourne, 1889, n.s., 3, 542- 559- HiscHLERD ET Terray, Croosi hetil, Budapest, 1889, XXXIII, 635-649- GiRODE, Bidl. Soc. Anat., Paris, 1889, LXIV, 3-6. SoupouLT, Bull. Soc. Anat., Paris, 1889, LXIV, 273-275. Martin, Arch. Med. Beiges, Bruxelles, 1890, XXXII, 9-30. Jaccoud, Ga::. d. Hop., Paris, 1890, LXIII, 445-447. 384 THE SURGERY OF THE LUNGS Masci, Gas. d. Clin., Napoli, 1890, 1, No. 14, 1-4. Standhartner, Aerztl. Berlin, d. k. k. Allg. Krankh. zur Wien (1888), 1889, p. 66. Ebstein, Wien. Klin. Woch., Ill, 867-870. Mader^ Berlin d. k. k. Krankenast Rudolph-Siftung, Wien (1889), 1890,329-331. Laporte, Echo Medical, Toulouse, 1891, V, 377-379. Bastianelli, Bull. d. Societa Lancisiana d. Osp. di Roma, (1889-90), i89i,X, 35-53. Hewelke, Deut. Med. Wochenschr., Leipzig, 1891, 1130- 1134- O'GoRMAN, Med. Press and Cir., London, 1891, n.s., LIII, 673. Florschutz, Corr. Bl. d. Allg. Aerzt. v. Thungen, Weimars, 1891, LXX, 348-352. DuNN^ British Medical Journal, London, 1892, I, 1077. DeCeronville, Rev. de Med. de la Suisse Rom., Geneve, 1892, XII, 229-235. Delageniere, Cong. Franc, de Chir., Proc.-Verh., etc., Paris, 1892, VI, 585-596. Wells, New York Med. Journal, 1892, LVI, 199-208. Streng, Fortsch. d. Med., Berlin, 1892, 757-763. Lop, Gas. d. Hop., Paris, 1893, LXVI, 249-256. MoussoNS, Mem. et Bidl. de Med. et Chir. de Bordeaux, (1892), 1893,267-270. Fedotoff, Objazat pat. Anat. Izslied ntud. Med. Imp. Charkow Univ., 1893, II, 39-44- SiMONiN, Rassegna di Med. Moder., 1893, VIII, 499-506. Goelet, North Carolina Medical Journal, Wilmington, 1894, XXXIV, p. 217. Reimbach, Centrhl. f. Allg. Path., Jena, 1894, V, 649-656. HoFMOKL, Jahrb. d. Med. k. k. Krankenart, 1895, M., 1897, IV, pt. II, 273. Mader, Morbus Addisonii, Jahrb. d. Med. K. K. Krankenart , 1895, M., 1897, IV, pt. II, 207. Parmerter, Buifalo Medical Journal, 1895-96, XXXV, 209- 215- GANGRENE 385 Babes, Semaine Med. de Paris, 1895, XV, 538-540. Pique, Ga^. Med. de Paris, 1895, 9 s., 33, p. 411. Mery, Bull. Soc. Anat., Paris, 1897, LXXII, 225-230. Alexsleyeff, Dictst. Med., Moskowa, 1897, ^I' 463- Vekonet, Laitop Russk. Chir., St. Petersburg, 1897, II, 931- 939- 'Ev^ AWT, Lancet, London, 1897, 1, 1681. Dalziel, Glasgow Medical Journal, 1897, XLVIII, 211-213. ViLLiERE, Paris, 1898. Patton, Clinical Reviezv, Chicago, 1898-99, IX, 165-169. Rendu, Bidl. et Mem. Soc. d. Hop., Paris, 1898, XV, 498. Zaleski, Ga^. lek., Warszawa, 1898, XVIII, 85-91. FussEL, Transactions Path. Soc, Philadelphia, 1898, XVIII, 85-91. Besson, Journal d. Soc. Med. de Lille, 1898, II, 566. Fernet, Bidl. et Mem. Soc. Med. d. Hop., Paris, 1899, XVI, 275-282. Swan, Boston Medical and Surgical Journal, 1899, CXL, 38. Bramwell, British Medical Journal, London, 1899, I., 70-75. Derereaux, British Medical Journal, London, 1899, !> 532- Robertson, British Medical Journal, London, I, 402. Warrack, British Medical Journal, London, 1899, I, 401. Peyrot et Milian, Presse Med., Paris, 1900, I, 201-202; i trace. Lenhartz, H., Mitteilungen a. d. Grenzgehieten (Jena), IX, 3- Garre, Journal American Medical Association, March 22, 1902, p. 798. McArthur, L. L., Gangrene of Lung Operation Transactions Mississippi Valley Med. Association, 1903. CHAPTER X RUPTURE Authentic reports of this condition began with Hick's case of a child, suffering from a cough resembHng pertussis, whose lung ruptured about two weeks after the cough began. Rupture, without injury to the chest wall, has been reported, especially by Ashhurst. This condition occurs oftener in children than in adults, and if death results, it is usually within five days. There may be laceration of the lung with- out blood-flow, as verified by a specimen in St. George's Hospital Museum. A four-inch laceration, two inches deep, resulted without hemoptysis. The mechanism of the rupture of a lung without fracture is the same as that which occurs when an inflated paper bag is struck by the hand. Gosselin's explanation is that it is due to a sudden pressure exerted on the thoracic wall, at the moment of full inspiration, concurrently with a spasm of the glottis or obstruction of the larynx. Consequently the lung bursts. Extravasation of air takes place, resulting in emphysema, pneumothorax, etc. Others discard this theory because it does not also ex- plain cardiac rupture from external violence on the thoracic walls. They claim that the rupture is due to direct pressure, as in the case of heart rupture without fracture of the ribs. But it is possible that the rupture of a small bronchial artery within the parenchyma of the lung may be the occasion of a rupture in some cases where there has been no external injury to the chest wall. 386 Plate LVI. Lungs of a hog- showing cysts caused by Uuig flukes (reduced) from i6th Annual Report U. S. Bureau of Animal Industry. (Chapter on Animal Parasites.) RUTTURE 387 The alveolar tissue being so fragile, the bursting of a very small artery may do great damage. One such case has come under the author's observation, and many more may have occurred, the real cause being overlooked. Ashhurst collected the histories of thirty-nine cases of rupture of the lung without fracture; of these twelve recov- ered. Otis has collected reports of twenty-five cases of this form of injury from military practice exclusively. These were generally caused by a blow upon the chest by a piece of shell, or other like missile. Among the twenty-five cases there were eleven recoveries. Historical (1840-1903). — Tait, of Edinburgh (1844), was among the first to report a case of rupture of the lung. Bar- low (1844) reported a case of hydropneumothorax with tuber- culous perforation. Strong (1850) also reported a case. Ferrari (1855) speaks of rupture of the lung by deep inspiration; DunHn (1855) reported a lesion of the lung caused by compression. Coulon (i860) reported a case of rupture of the lung caused by the passage of a wagon-shaft through the chest. Skay had a case without external injury. Galvez (1864) reported a case from violent contusion without fracture of the ribs, resulting in instant death. Bermutz (1865) reported a case of rupture following suppuration. This case was cured. Ashhurst (1871) men- tions a case of rupture, without injury of the thoracic parietes. Watson (1881) reported a case of laceration of the lower lobe of the right lung caused by violence without fracture of the ribs, which terminated in death. Gould (1882) reported rupture of the lung, with pneumothorax; paracentesis was performed, followed by recovery. Gross (1882, Vol. II, p. 368) says that rupture of the lung, without injury to the thoracic wall, is not so frequent as at one time supposed. Laurent (1883) reported a rupture of both lungs, with external injury, followed by death. Uck- niar (1889-90, and 1890-91) published his contributions on 388 THE SURGERY OF THE LUNGS rupture of the lung. Buttell (1892) published a work on the general treatment of lung wounds. Kerr (1894) reported a case of rupture of the lung, associated with fracture of the ribs, with early subsequent recovery. De Sanctis (1894) reported his method of suturing in lung rupture. Comte (1894) published his notes upon a case of rupture of the lung, and Hermanid (1898) reported a case of rupture from whooping cough. Wallingford and Roberts, of Paris, Ky., were called to see a negro who had died suddenly. He was a stout, robust fellow with a good history. The autopsy revealed nothing to account for the rupture of the lung except that one of the bronchial arteries had ruptured. The rupture of the artery was doubtless due to erosion by a deposit of coal dust, which had become infected. The negro was a coal-heaver. (For Treatment and Symptoms, see Chapter on Lacerated and Incised Wounds.) BIBLIOGRAPHY Hicks, London Med. Gaz., April 22, 1837, 119. Tait, Jour. Med., Edinburg, 1844, I, 104-107. Barlow, Lancet, London, 1844, I, 604. Strong, Am. Jour. Med. Sc, Philadelphia, 1850, XIX, 72. Ferrari, 1855, Raccogliatore Med. di Fauc, 2-2, XI, 413-433. DuNiN, Arch. Path., etc., Verl, 1855, CII, 323-345. CouLON, Bull. Soc. de Chir., Paris, 1860-61 — 62, s. i, 673-676. Skey, Med. Times and Gaz., London, 1862, II, 59. Gould, Lancet, London, 1862, I, 457. Galvez, Aur. Acad, de ciennied, etc., la Habana, 1864-65, 1, 28-30. Bermutz, Jour, de Med. et Chir. Prat., Paris, 1865, 2 s., VI, 405. AsHHURST, 1874, Trans. Path. Soc, Philadelphia, 1871-73, IV. 129-33- Watson, Bull. N. Y. Path. Soc, 1881, 2 s., I, 228-230. Plate LVII. Posterior View of Heart and Lungs of Dog. In- jected IN Situ. (Description, page 484.) RUTTURE 389 UcKMAR, Monitore Med. Morchigiano, Loreto, 1889-90, III, fasc. II, 107-132. UcKMAR, Gior. Internaz. d. Soc. Med. Napoli, 1891, n. s., XIII, 921-941. BuTTEL, Halle a S., 1892, p. 40. Kerr, Med. News, Philadelphia, 1894, LXIV, 214. De Sanctis, Rijorma Med., Napoli, 1894, X, pt. I, 98-101. CoMTE, Rev. Med. de la Suisse Rom., Geneve, 1894, XIV, 191-197. AsHHURST, Int. Clin., Philadelphia, 1894, 4 s., Ill, 151-161. Hermanid, Tjdsch. v.v. Genessk., Amsterdam, 1898, 2 r., XXXIV, d. 2, 404-407. Wallingford and Roberts, Cincinnati Lancet Clinic, March 9, 1901. CHAPTER XI HERNIA Hernia, or pneumocele, is where a portion of the lung protrudes through the chest wall, or below the clavicle, or through the diaphragm. In most definitions of hernia of the lung it is stated that the protrusion of the lung may be through the chest wall or through the diaphragm. How- ever, although many cases of diaphragmatic hernia of the ab- dominal viscera are recorded, there is but one instance where the lung has protruded through the diaphragm. When it does so occur, it is likely to be on the left side. Out of two hundred and seventy-six cases of hernia of the abdominal viscera through the diaphragm reported by Lacher, two hun- dred and twenty-five were on the left side. The support afforded by the liver on the right side prevents the escape of the abdominal viscera into the thoracic cavity. Hernia of the lung may be primary or secondary, and is usually traumatic. It is not often subcutaneous. As a rule, a slender apex enters a small opening in the chest wall or diaphragm. The protrusion is increased by inspiration and decreased by expiration; and, if not immediately returned to the pleural cavity, will sooner or later become hard and dry. If not immediately reduced, the adhesion to the adjacent soft tissues will be so firm that operative measures will be necessary to release it. Hernia of the lung is to be differentiated from chronic abscess, from hernia of omentum, intestines, or liver upon the right, and of the stomach or pericardium upon the left. 390 HERNIA 391 Hernia is generally sudden, but may be gradual, or appear subsequently. If late, it may be free from adhesions, and therefore reducible. It is more frequently in the right lung, owing to the latter having one more lobe and fissure. It is not necessarily fatal, nor does it shorten life. It is very rare, and may vary in size from that of a hazel-nut to that of the human head. Operative measures should not be resorted to, unless gan- grene should ensue. It is indicated if the tumefaction be troublesome by giving pain or by undue prominence. The subcutaneous form of hernia of the lung is said to be always reducible. Some teach that if the hernia protrudes externally through the cutaneous structures, reduction must be attempted. If this fails, or if gangrene appears, the protruded part must be removed, or allowed to slough away. The other variety of hernia of the lung may be reduced and held in place by pad or belt. Historical (1499-1903). — Rolandus (1499) published one of the first reports of a surgical operation for hernia. It is worthy of reproduction. " Called to a citizen of Bologna on the sixth day after wound, I found portions of the lung issued between two ribs. The afflux of the spirits and humors had deterrpined such a swelling of the part that it was not possible to reduce it. The compression exercised by the ribs retained its nutri- ment from it, and it was so mortified that worms had de- veloped in it. " They had brought together the most skilled Chirurgeons of Bologna, who, judging the death of the patient to be inevitable, had abandoned him, but I yielded to his prayers and those of his parents and friends, and, having obtained leave from the Bishop, the Master, and the man himself, I yielded to the solicitations of about thirty of my pupils, making an incision through the skin, the breadth of my little finger- nail, away from the wound, all round it, then with a cutting 392 THE SURGERY OF THE LUNGS instrument I removed all the portion of the lung level with my incision. " The wound resulting from the resection was closed by the issuing from my incision. By the grace of God it cicatrized and recovery took place. " It is true that one had to wait long for it. " The patient, with his master, Rolandini, has since made a voyage to Jerusalem, returning in good health. " If you ask me what I should have done in this case, I answer: I should have dilated the wound with a small piece of wood, keeping the lung warm with a cock or fowl, split down the back, or should then have reduced it and kept the wound open until the portion of the lung was wholly mortified. " If you still question me to know how this man can live without his lung, I answer: That the part remaining in the chest profits by the nutriment destined for the whole lung, and so is developed. Nature has been able to create supple- mentary parts in it, which is an easy thing, that is so soft and near the warmth of the heart." Tulpius (1674) ligated and cut off three ounces of a herni- ated lung ; the patient recovered. Chassier also mentions a her- niated lung, and was the first to give it special consideration. Erichson reports a case in a cornet player. Boerhave's case (1814) was due to child-birth, and occurred in the mother. Cloquet ( 1819) reports a case in a man thirty-two years of age, who was crushed under a gun-carriage, but recovered. Morell-Lavallee collected thirty-two cases of hernia of the lung. Forde (1837) reports a case in which a protruding portion of the lung was removed. Lake (1852) reported a case of hernia of the lung, caused by the handle of a wheel- barrow penetrating the side of the chest. Dufour (1855) reported a case of traumatic hernia cured without an opera- tion, after having caused much loss of blood. Hale (1856) details a case which required removal of a part of the left lung. HERNIA 393 In twenty thousand wounds during the War of the Re- belHon there were only seven hernise of the lung. Cockle (1873) published a case of double pulmonary hernia. Lewtas, of India (1876), reported a case of congenital hernia. From the same country another native physician (1878) reported a case of wound in the chest with protrusion of lung, and death. H. Hirschprung (1879) reported a case of congenital hernia of the lung, and Beale reported an equally interest- ing case of hernia through the diaphragm. Hagentorn (1892) speaks of a case of pneumonotomy in pneumocele. Malpeli (1892) mentions " pneumonotomies." Muller (1893) resected the lung with gratifying results. Pitt's lecture (Lancet, October 14, 1893, and Transactions Ninth French Surgical Association) states that the protrusion occurs at once, or at any time later. Lopez (1894) reported a resection of the lung for hernia, with recovery. The year 1894 marks an epoch in Japanese surgery, and Karotta, a rising young surgeon of that country, excised a herniated lung with success. Omar (1894), of Lyons, made a total extirpation of a lung. Llobet, Reclus, and TufHer (1895) all mention re- sections of the lung, and Knox reported two cases of hernia of the lung into the neck. From 1895 to the present there have been several cases of hernia of the lung and its treatment reported by Nagy, Roussell, Martiny, von Nagy, Wightman, Gaillard, Vogeler, Rotenpeiler, and Potain, Reymei, of Paris (1895), reported a successful operation for traumatic hernia of the lung. Convey collected four- teen cases of removal of portion of lung, with twelve recov- eries. Heydweiller says: " It is safe to remove it," referring to the protruding part of the lung. Vulpius, of Berlin (1900), reported a case of hernia of the lung resulting from injury. Five weeks after a plastic operation the patient was dis- charged, cured. 394 THE SURGERY OF THE LUNGS Symptoms and Diagnosis. — These are very definite. The front and side of chest and the lower costal spaces are more frequently the site. Old adhesions prevent hernia. Morell-Lavellee and Otis maintain that the hernia is not increased on inspiration and decreased on expiration. Slow, natural expiration should not increase the tumefaction, but it is far different when expiration is violent. Paget says a sudden puncture of the chest is followed by immediate expiration, with closed or half-closed glottis, raising the pressure in both lungs, or causing overflow of air from the sound into the injured lung, and thus the hernia is brought about; without cough or violent expiration it could not occur. A gradual hernia may have a true sac lined with pleura, free from adhesions, and reducible. Protrusion is always accompanied by vesicular murmur and a crackling sound. There are many successful reductions reported. The only certain relief is to remove the ribs and return the protruding parts. Treatment. — The removal of a section of one or more ribs should be avoided if possible. The protrusion of the lung, as a rule, is through the intercostal space, but occa- sionally it will protrude through an opening in the chest- wall, as a result of displaced fracture of the rib. If the herniated sac is lined with pleura, reduction is usually very easily accomplished. If not, great difficulty is encountered. In either event, reduction may be impossible. If reduction can be accomplished by manipulation, the open- ing can easily be closed perfectly and permanently by incorpo- rating in the sutures periosteum, or ribs, or fragments there- from. If the sac is lined with pleura, and reduction cannot be done by manipulation, sections of ribs should be made. After the lung has been returned to the pleural cavity the opening should be closed in a similar manner. That is, by suturing Plate LVIIl. d >j/;4|^ 'm "1 ...v^W'-: . N^ y^ ^v A / 1 4 ^:'^ j#^ 1-^ ^ J Ik IB&itt^ 00 Q o V "^ "^^ o '%..'■' \^ c75 HERNIA 395 the periosteum, or ribs, firmly together, dividing them if necessary (osteoplasty). If there is no pleural membrane incorporated within the hernial tissue, and the hernia can be returned to the pleural cavity, the opening in the chest is to be closed as directed above; but if it cannot be returned to the pleural cavity by manipulation, and the protrusion is through the intercostal space, amputation of the projecting mass is the only resource left. This should be done only after transfixing it with a liga- ture, to prevent haemorrhage, and the integumentary tissue, together with the periosteum, if possible, should be subse- quently sutured over it. BIBLIOGRAPHY BoERHAVE, Bull, de la Fac. de Med., Paris, 1814, IV, p. 50. Chassier, Bull, de la Fac. de Med., Paris, 1814-15, IV, 50-54. Morell-Lavallee, Traite des Mai. Chirurgie, 1824, VII, 266. FoRDE, Med.-Chir. Transactions, London, 1836, XX, pp. 378-381. Lake, Dublin Quart. Journal Medical Science, 1852, XIII, 231-233. Hale, Transactions Medical Sciences, Philadelphia, 1855, V, 40. DuFOUR, Compt. Rend. Societe de Biologic (1854), Paris, 1855, 2 s., I, pt., 2, 15-24. Cockle, Medical Times and Gazette, London, 1873, I, 5-31. Lewtas, Indian Medical Gazette, Calcutta, 1876, XI, 212. LiUGH, Indian Medical Gazette, Calcutta, 1877, XII, 245. HiRSCHPRUNG, Hasp. Tid. Kjobent., 1879, 2 r., II, 953-959. Beale, Lancet, London, 1882, I, 139. Reymer, Medical Week, Paris, 1895, III, 537. RoussEL, Arch, de Med. et Pharm. Mil, Paris, 1895, XXVI, 61-69. QuENU, Gazette Med., Paris, 1895. Nagy, Orvosi hetil., Budapest, 1896, XI, 29. Martin Y, Bull. Acad. Med., Paris, 1897, XXXVIII, 140. VP.N JSTagy, Centrbl. }. d. Therap. 396 THE SURGERY OF THE LUNGS Gailliard, Bull, el Mem. Societe Med. Hop., Paris, 1897, XIV. 946. WiGHTMAN, British Medical Journal, London, 1898, I, 365. VoGLER, Monatschr. /. Unjalheilk., 1898, V. 169-176. RoTHEMPiELER, Wien. Med. BlalL, 1898, XXI, pp. 471-473. PoTAiN, Semaine Med., Paris, 1898, Vol. XVIII. VuLPius, Berliner Klinische Woch., den Dec. No. 50, XXXVII, Jahrganz, pp. 11 52-1 154; i fig. CHAPTER XII CEDEMA QEdema is the effusion of serum, from many causes, into the submucous connective tissue. Flint says the transudation is primarily within the air-cells, the serum also infiltrating the interlobular structure. It may be slow or rapid, and is produced by several conditions, principally by acute and in- fectious diseases. The malignant form is due to a specific germ. Valvular disease of the heart is a prominent factor in its causation. Compression of the lung by a tumor of any char- acter, inhalation of hot or cold air, or gases, suppurative hepatitis, Hodgkin's disease, eclampsia, leucaemia, anaemia, or chlorosis, may cause it. It may be local or general, and is usually found in persons under fifteen years of age. It is indicated by dyspnoea, varying in intensity. Historical (i 891-1903). — Muller (1891) describes this con- dition in a most interesting manner, while von Basch reports a series of experiments to show its pathology. Anthony (1891) speaks of a case of pulmonary oedema, secondary to nephritis, complicating pregnancy. Smith (1891) reports a case, while Grossmann (1891) verified the work of Basch by his experimental research. Ferri (1893) reports a case of pulmonary oedema after the publication of one by von Ziesell (1893). Lowith (1893) also mentions an interesting case. Corin (1897) mentions a case of pulmonary oedema, while Milian (1897) speaks of pulmonary sclerosis, and Flava (1897) mentions kaolinosis. 397 398 THE SURGERY OF THE LUNGS Freyberger (1897) speaks of an anaemic infarct in the lung. Furinami (1898) also speaks of a haemorrhagic infarct into the lung, which caused pulmonary oedema. Paulain, Natale, and Fouineau (1898) each make mention of cases. Fouineau (1898), in a most interesting article, mentions the rarity of pulmonary oedema. Momburi reported a case of pulmonary apoplexy and thrombosis. Muller showed by his experiments that if the vagi be divided in the neck, death will result from the in- filtration of the lungs and air-passages with serum. Hasse remarked a peculiar fact in cases of general dropsy which prove fatal, viz., that one lung is always found adherent to the pleura, and the other is not. The adherent lung is oede- matous, and the other is compressed by hydrothorax. Symptoms and Diagnosis. — There is increased frequency of respiration with dyspnoea, and dulness on percussion. The respiratory murmur is lost, or very feeble. The vocal reso- nance may be increased. The presence of liquid is denoted by fine mucous or subcrepitant rales. The pulse is rapid and feeble. When the efYusion involves the interstitial tissue, cyanosis appears, and there is often intense suffering. The sputum increases with the increase of serum in the alveoli. It is often thin and watery, and sometimes viscid. In this case it increases the dyspnoea by obstructing the larynx. It is at times tinged by the presence of red blood- corpuscles. Urea may also be found in the sputum. There is no fever unless there are complications. In ex- treme cases the patient dies from heart failure and carbonic- acid poisoning. Bianci's phonendoscope is claimed to be a useful instrument in tracing the progress of the oedema. CEdema may be differentiated from bronchopneumonia by the physical signs, which in the latter disease show no marked difference between the affected and the non-affected areas. The mucous rales occur late in the bronchopneumonia, while they are present from the begiiming in oedema. Plate LIX. 1-n 00 Q P K a CO (EDEMA 399 Hydrothorax, too, possesses some things in common with oedema, but in hydrothorax change of position of patient will alter the area of dulness. Treatment. — Measures are to be directed to the causative diseases. At the same time, use every means to sustain the heart's action. Phlebotomy has been advocated, and Hu- chard says that the best treatment for the acute form is venesection from the arm. (See also Treatment, in the Chapter on Gangrene and Abscess.) Apply the same surgical measures as used in abscess and gangrene of the lung, and in addition, employ the syphilitic remedies. Abscess and gangrene of the lung caused by syphilis cannot be differentiated from pulmonary abscess and gangrene from other causes. Not all cases of abscess or gan- grene of the lung in a syphilitic patient are due to syphilis, for these diseases may exist as complications of syphihs. Whether the cause of the abscess or gangrene is syphihs or not, it should be treated as if it were. Abscess, gangrene, and syphilis of the lung present nearly the same physical signs. Often it is only by the closest study and a full knowledge of the patient's history that any- thing like a satisfactory diagnosis can be made. Foetor of the breath is common to all three. In gangrene the foetor is intensely foul and persistent. In abscess there is foetor, but it is not excessive, nor does it have the peculiar gan- grenous odor. Pulmonary abscess must not only be differ- entiated from gangrene, but also from putrid bronchitis. In the latter disease, the odor of the breath resembles acacia blossoms. Gangrene is also to be distinguished from putrid bronchi- tis. In this last disease the sputum does not contain shreds of lung tissue, nor is there the fatal marasmus that accom- panies gangrene. It should also be remembered that oedema may result 400 THE SURGERY OF THE LUNGS from either of these diseases, or from the maladies which gave rise to them. In oedema the sputum is of diagnostic importance. At times it is thin and watery, and again viscid. It may at times be colored, and in this case the color is due to the presence of red blood-corpuscles. It may also con- tain urea. But when the sputum splits up in the three char- acteristic layers, as described in the chapter on Gangrene, there can be no mistake, and whatever else may be found on thorough examination, you may rest assured that you have a case of pulmonary gangrene. CEdema is to be carefully differentiated from broncho- pneumonia. Rales are present from the beginning in oedema, but not until rather late do they appear in bronchopneumonia. Hydrothorax is easily distinguished from oedema, because change of position produces an alteration in the area of dulness. In all the diseases considered here, temperature is not a positive diagnostic factor. It may be present or it may be absent. It is, usually, a sign of infection when it does exist. Surgical treatment is essentially the same for all three diseases. Nothing should be done rashly. Make sure of your diagnosis, and then operate boldly. BIBLIOGRAPHY KovACS, Wien. Klin. Woch., 1891, 41-45. MuLLER, Corr. Bl. f. Schw. Aerzie, Berlin, 1891, XXI, 432-438. VON Basch, Bd. Beitrage zur Pathologie des kneislaufe lungen- oeden cardiaie. Berlin, 1891, 221 p. Anthony, Boston Medical and Surgical Journal, 1891, CXXXV, 468. Smith, Med. Rec, New York, 1891, XL, 730. Grossmann, Ztschr. }. Klin. Med., Berlin, 1892, XX, 397-406. Ferri, Rassegna Med., Bologna, 1893, I, No. 6. von Zeisell, Centrlhl. }. Phys. Leipzig u. Wien, 1893-94, VII, 702. cedema 401 LowiTH, Beitrage zu Path. Anat. u. Allg. Path., Jena, 1893, XIV, 401-442. CoRiN, Slalper, Li^ge, 1897-98, I, 277. MiLiAN, Bull. Anat. Soc.j Paris, 1897, LXXII, 496-516. Flava, Wien. Klin. Rundschau, 1897, XI, 609. Freyberger, Trans. Path. Soc, London, 1897-98, 27-30. FuRiNAMi, Arch. /. Path. Anat., 1898, CLIII, 61-193. Paulain, Presse Med., Paris, 1898, II, 362. Natale, Gior. Internaz. d. Med. Soc, Napoli, 1898, XX, 988-992. FouiNEAU (Raoul), Paris, 1898, 268, No. 133; Medical News, 1898, LXXIII, 714-716. MoMBURi, Courier Medical, Paris, 1899, LIX, 2-4. CHAPTER XIII POLYPI IN THE BRONCHIA Only a few cases of polypi of the bronchia have been reported. Many cases have been overlooked or else have not been clearly diagnosticated. Polypi may degenerate, or slough, and be coughed up and expectorated, and thus escape detection. No doubt, many obscure cases of pulmonary dis- ease are due to polypi in the bronchia. There are several reports of fibrous growths in the bronchia. Cases of this character are, perhaps, many times due to polypi which have degenerated. The same is also true of hyperplasi^e. So, too, many cases of haemoptysis that have appeared inexplicable may have been caused by polypi. The titles of many papers indicarte that their authors were not sure of their diagnosis. It is very probable that polypi of the bronchia are not so exceedingly rare as some writers assume. Just what effect polypi in the bronchia have on the lungs is unknown. Polypi in the lungs themselves have been reported by some ob- servers. In case of a very large polypus in the bronchia there is danger of the bronchia being occluded. If it be one of the ultimate bronchia, the result may not be very serious, but in case of the larger many grave complications may arise; not only from the occlusion of the bronchia, but the increase in growth of the polypi, will cause a dilatation. The excessive dilatation of the larger bronchia exerts great pressure on the neighboring tissue of the lung. There results from this, not only a loss of lung capacity, but the 402 Plate LX. 00 ^^^Y*^ o D POLYPI IN THE BRONCHIA 403 blood supply is shut off, and this portion of the lung may become gangrenous or atrophied. Abscesses may also re- sult from polypi in the bronchia. If a polypus becomes degenerated, or is torn loose by the movements of the lungs in efforts to expel it, the lungs may become infected. The mere presence of polypi in the bronchia does no harm, but the increase in size of the polypi may cause gan- grene, by constriction of the blood-vessels. Historical (1700-1903). — Clark (1700) reported a case of polypus of the lungs, and Bussiere reported a similar case. Samber (1719) reported a case of polypus which was coughed up from the windpipe. Nichols had a somewhat similar case in which the expectorated polypus resembled a branch of the pulmonary vein. Strack (1799) published a work on " Polypi as a Causative Factor in Pulmonary Dis- eases." Acharius (1802) wrote a paper on a case of pul- monary polypus. Cheyne (1808) had a case of bronchial poly- pus. Hankel reported several cases of chronic tracheitis and bronchitis due to polypi. Middlendorff (1837) published a dissertation on polypi of the bronchia. North (1838) gave an account of two cases of bronchial polypus. Berliner (1848) published a work on polypi of the bronchia. Oppolzer (1858) had a case of chronic tracheitis and bronchitis due to polypi. Morris (1862) re- ported several cases of bronchial polypus. Commandre ( 1872) observed polypi form masses in the bronchia. Warren (1876) published a paper on the nature, etc., of bronchial polypi. Symptoms. — The symptoms of polypi in the bronchia are very similar to those caused by the benign tumors. If the poly- pus has a pedicle, there will be a noticeable change in the bron- chial sounds. This will be caused by the polypus swinging back and forth, but when the growth of the polypus produces occlusion of the bronchia, the sounds will cease. Hearn and Roe {American Magazine, July 1901) reported 404 THE SURGERY OF THE LUNGS a case of pneumonotomy for abscess of the lung, due to a poly- pus. Two operations were performed ; on making an exami- nation of the abscess cavity, after the second operation, a poly- pus was found extending into the abscess cavity. These writers believe that localized gangrene was responsible for the trouble. They claim that the abscess cavity was not a saccular bronchiectatic cavity; but it is very probable that the polypus observed after the second operation, was the prime cause of the abscess. It is not likely that a polypus, several centimeters in length would have developed in the interval, between the two operations. Nothing is said to indicate that the polypus had been seen before the examination of the cavity. This case illustrates the importance of a thorough knowl- edge of the condition of the lesion in all pulmonary troubles. This is necessary, not only for diagnostic purposes, but that the proper surgical procedure may be selected. CHAPTER XIV ATELECTASIS APNEUMOTOSIS Atelectasis pulmonum (imperfect expansion of the lungs) is a condition more often spoken of in literature than found in actual practice. Atelectasis, collapse, or carnification is rare and always congenital. When caused by continued compression of the lung by fluid, new growth, gauze packing, or compression from any cause after birth, it is termed apneu- motosis. " Congenital atelectasis is of great medico-legal import. This much has been demonstrated, notwithstanding the contro- versies which have arisen among pathologists: i. That atelec- tasis may continue indefinitely as a foetal condition, and occur in infants who have lived, breathed and even cried. 2. The presence of much pigment shows that the affection has not de- veloped before the fifth year. 3. The absence of pigment does not necessarily show a foetal condition, because the pigment may have been absorbed in the process of time. 4. Complete absence of air from the alveoli is an evidence of death before birth. 5. Aspirated products found in the air passages is abso- lute evidence of respiration " (Abrams). Mechanism of Collapse. — Lichtheim demonstrated that in bronchial obstruction, the air is absorbed by the vessels of the alveolar walls, aided by the inherent lung elasticity. The oxy- gen is most, and the nitrogen least rapidly absorbed. Obstruc- tion collapse may occur in any part of the lung, but the site of predilection is the lower lobes. Here, many factors are in- volved in explanation of this fact. Insomuch as bronchitis is 405 406 THE SURGERY OF THE LUNGS a common cause of obstruction, the secretions gravitate to the most dependent parts. Again, the lower chest is more phant and mobile, and is, therefore, very susceptible to external atmos- pheric pressure. Complications. — " i. The atelectatic areas may pass into a condition of fibroid induration. 2. Dilatation and hypertrophy of the right heart are present, due to causes which will be dis- cussed in the next chapter, on emphysema. 3. Thrombosis is present in the brain sinuses, due in part to the imperfect circula- tion, and in part to the debilitated condition of the system. 4. There is compensatory emphysema, the healthy lung assuming the functions of the collapsed areas. 5. There is persistence of the foramen ovale and ductus arteriosus. These channels are closed normally within two weeks after birth, but they may remain patent, owing to the enfeebled respiration which causes the blood to linger in the right heart, and to utilize the foetal channels for voiding its contents " (Abrams). Historical (1832-1903). — Joerg (1832) reported a case of morbid pulmonary organ, and imperfect respiration from birth. G. H. Barlow (1841) published his observations on certain dis- eases originating in early youth, illustrating his position by three cases of defective expansion of the lungs. Spangenburg (1844) had a case of atelectasis with uterine respiration. Fischer ( 1851 ) reported a case of infantile atelectasis pulmonis. In 1852, appeared Meig's paper on atelectasis pulmonum and collapse of the lung in children, with cases. Cockle ( 1856) reported a case of acquired atelectasis (carnification) of the en- tire upper lobe of the right lung, from direct mechanical press- ure. Ward (1856) reported a case of enlarged thymus, and atelectasis, in an infant which survived its birth four hours. Kunkler's work throws some light on this questionable con- dition. His work prepared the way for Hewitt's discoveries concerning apneumotosis or pulmonary collapse, and observa- tions on the diagnosis and treatment of such cases. Clark (1859) reported a case of carnification of the lungs in an in- ATELECTASIS ATNEUMOTOSIS 407 fant. Thomas (1864) had a case of complete atelectasis of the lungs. Houston (1867) reported a case of congenital atelec- tasis, with death after the establishment of respiration. Stevens gave an account of two cases of collapse of an en- tire lobe of the lung, without displacement of the thoracic viscera. Long reported a case of pulmonary collapse caused by hnsmoptysis. T. Barlow (1879-80) reported an interesting case of atelecstasis of the lungs, emphysematous cysts, and con- genital heart disease. Meigs (1879) reported a case of col- lapse of the lung, and cyanosis in a young infant, produced by violent crying. Francke (1883) also reported cases of atelec- tasis. Owen (1886) tells of a case of complete collapse of both lungs, without organic disease or mechanical injury. Adams published in 1898 an article on postnatal atelectasis. The Italians have been especially interested in this subject. At Kiel (1891) appeared an article on a case of atelectasis compli- cated by bronchiectasis. Werner also published an' account of a somewhat similar case. Abrams (1894) published his obser- vations on the pathology of pulmonary atelectasis. Desplats (1894) had a case of gastrointestinal apneumotosis, which caused atelectasis of the two lower lobes of the lung, and death by asphyxiation. Patton's work on bronchiectasis (1898-99) with those of Whitney, Starr, and Case, and their reports of one-sided chron- ic pulmonary atelectasis, brings the published knowledge up to date. Symptoms and Diagnosis. — It is only when the atelectasis is extensive that the condition in the infant is recognized, small foci giving rise to no demonstrable manifestations. Cough and fever are absent as a rule. Cyanosis is usually marked and pro- gressive, and corresponds to the impaired respiratory move- ments and imperfect chest expansion. The cyanosis is specially prominent in the face and fingers. The pulse is feeble, rapid, and irregular. Physical examination of the chest shows recession of the 408 THE SURGERY OF THE LUNGS lower thorax with each inspiration. If the child cries during the examination, it does so with difficulty, and the cry is no more than a moan. Percussion shows dulness, usually marked in the infero- posterior portions of the lungs. The percussion below must be light, otherwise one only obtains impaired resonance. If the hand of an assistant is made firmly to compress the thorax above the area percussed, any dulness, if present, is accentu- ated; the compressing hand confines, as it were, the thoracic vibration, and prevents its transmission to the percussional area. Auscultation is by no means conclusive. The respiratory murmur, although usually absent or enfeebled over the atelec- tatic area, may be intensified to bronchial breathing. Pathology — A part or all of the lung may be involved in either atelectasis or apneumotosis. The tissue is non-crepitant, smooth, dark blue, or purple in color; becoming hard and dense with age of the child, if not aerated soon after birth. Bronchitis is the most common cause. Paralysis of the pneumogastric nerve as the result of press- ure from tumor, injuries, or otherwise, is also a causative factor. " The dyspnoea is of the inspiratory type " (Abrams). Treatment — " Place in fresh air, induce vomiting, and try artificial respiration, remove mucus from mouth and throat, with gauze or finger. Induce cutaneous stimulation by alter- nating hot and cold water ; try rectal divulsion with finger and rhythmical contraction of the tongue " (Laborde). Mouth to mouth inflation of the lungs, with tongue of pa- tient drawn forward and his nostrils closed, is a useful proced- ure. Emetics should not be given, as they are useless. Plate LXI A. B. Transverse Sections of the Heart and Lungs. (Description, page 485.) ATELECTASIS APNEUMOTOSIS 4O9 BIBLIOGRAPHY JoERG, Dublin Journal Med. and Chem. Society, 1834, V, 36-41. Barlow, Guy's Hospital Reports, London, 1841, VI, 235-264. Fischer, Berlin, 1841. Spangenburg, Marburg, 1844. Meigs, American Journal of Medicine, Philadelphia, 1852, n. s.. XXIII, 83-102. Cockle, Association Medical Journal, London, 1856, II, loio. Ward, Pathologic Society, London, 1858, VIII, 99. KuNKLER, Louisville Review, 1858, 494-501. Clark, Lancet, London, 1859, I, p. 92. Thomas, Nederl. Tijdschr. van Geneesk., Amsterdam, 1864, III, 337- Houston, Leavenworth Medical Herald, 1867-68, I, p. 303. Stevens, Medical Association, St. Louis, 1870, V, 35-38. Hewitt, Lancet, London, I, 625, 1857; and Reynolds' System of Med., Vol. Ill, p. 862-882, 187 1. Long, Lancet, London, 1875, II, 49. Barlow, Transactions Pathologic Society, London, 1870-89. Meigs, American Journal Obstet., New York, 1879, XII, 68-81. Francke, Deut. Arch. Klin. Medicin., Leipzig, 1883, LIII, 125-143- Owen, American Lancet, Detroit, 1886, X, pp. 205-7. Adams, American Text-book, Dis. of Child. Tanessia (Sunto), Attir. ist. Veneto di sc. lettedarti, 1889, VII, I 303-1 306. Berlin, Kiel, 1891, 14. Werner, Dresden, 1891, p. 36. Abrams, Med. Rec, New York, 1894, XL VI, 269. Desplats, Journal de Science Med. de Lille, 1894, I, 545-553. Gallet, Clinic, Brussels, 1894, VIII, 609-616. Whitney, Boston Medical and Surgical Journal, 1898, CXXXIX, 616-619. 4IO THE SURGERY OF THE LUNGS Starr, Philadelphia, 1898, 2d pp. 899-903. (Diseases of Child.) Patton, Clinical Review, Chicago, 1898-99, VIII, 219-223. Case, Lancet, London, 1899, I, m; " Hertz's Handbuch," edited by Ziemssen, Volume V, p. 418. Abrams, a., The Medical Fortnightly, March 10, 1903, pp. 193- 201. CHAPTER XV SYPHILIS Syphilis being next to tuberculosis in importance as a causative factor in lung abscess and gangrene, should be con- sidered. Unlike their action in tuberculosis, remedial agents for syphilis will prevent, at least to a very great degree, the formation of lung abscess and gangrene, if they will not at all times cure them. There are, perhaps, no pathologic lesions more easily influenced or completely overcome by medicaments than those caused by syphilis. It is, therefore, proper to use the remedies for syphilis to the maximum degree, not only before abscess, or gangrene, or both, manifest themselves, but during their existence, and after any operative measure that may have been employed. Not all cases of lung syphilis terminate in abscess or gan- grene. Such conditions are indeed few, in comparison with those of syphilitic tubercle, that are not arrested in their course, and overcome by proper medication before such a destructive stage is reached. Historical (1797-1903). — The literature of this subject be- gins with the publication by Zadig in 1797, of a paper on dis- eases of the lungs from venereal sources. Then nothing ap- peared until 1 84 1. That year Munk published his paper on syphilitic diseases of the lungs. Ten years elapsed before any- thing else on this subject was published. Lagnean (1853) published his work on the diseases of the lungs, caused, and influenced by syphilis. Stevenart (1853) announced the fact, that constitutional syphilis often revealed 411 412 THE SURGERY OF THE LUNGS itself by grave changes in the lungs, etc. Aitken ( 1863) pub- lished his notice of pulmonary lesion, associated with syphilis. Fontain (1865) observed a case of syphilis of the lung, in an eight months foetus. Mescrede (1866) published a paper on the subject. Gintrac (1867) had a case of syphilitic phthisis. Negri (1868) published his paper on Some Practical Consider- ations concerning Syphilitic Diseases of the Lungs. Dr. Lindseth (1870) appeared with his work on syphilitic phthisis, laryngitis, etc. He boldly advocated certain ideas, which, at the time, caused considerable criticism. Ouvre was the most important of his critics. Depaul (1870) reported a case of syphilitic alterations of the lung at birth. We are also indebted to Fox for additional knowledge of syphilitic affection of the lung. Zelinski (1871-72) issued a paper on inflammation of the pleura in a syphilitic patient. Hand (1872) reported an inter- esting case of syphilis, accompanied by capillary bronchitis, and lobular solidification of the lung tissue. Huchard ( 1873) pub- lished his work on syphilitic tumors of the lungs. Goodhart (1873) also reported cases of syphilis of the lungs. Grandi- dier (1875) published a valuable paper on the same subject. Rollitt (1875) made a contribution to the literature of this subject. Fournier (1875) also published a report. His, how- ever, was more of a treatise on syphilitic phthisis. Pentinalli (1877) published a valuable paper on congenital and acquired syphilitic diseases of the lungs. Frey (1876) re- ported a case of infiltration of the lung from syphilis. Ma- homed ( 1876-77) published two cases of syphilitic disease and early fibroid of the lung. Gowers reported cases that came under his observation. De Bomilla (1876-77) reported a case of tracheobronchial adenoid, due to syphilis. Porter also reported a case of syphilitic phthisis, and Poggio the same year reported a case somewhat similar. Tiffany has a valuable paper on syphilitic diseases of the lungs. We are under obligations again to Pi-ate LXII. 1 RANsx'ERsi': Sections of tiie Luxgs. (Description, page 486.) SYPHILIS 413 an Italian, for Jaunuzzi's paper on hereditary and acquired syphilitic diseases of the lungs. Landrieux (1878) published a useful work covering all the syphilitic diseases of the lungs. Raindohr ( 1878) added much in the way of caring for these diseases by his work on methods of treatment. Vierling (1878) had a case of syphilis of the trachea and bronchia. Kortmann (1878) published an exten- sive treatise on syphilitic diseases of the lungs. Bresse ( 1879) published his study on a case of syphilitic phthisis in an adult. Proksch (1879) pubHshed his history of syphilis of the lungs; Warder reported a case of syphilitic disease of the pleura. Langehaus also reported a case; Eve and Schnitzler (1879) had several valuable reports on syphilitic diseases of the lungs. Sacharjiss (1879) contributed valuable lessons in his work on the diagnosis of syphilitic pneumonia. Henop (1879) also published a report on syphilis of the lungs. Cantarano (1880) furnished contributions to the clinical history of these diseases. Frank (1880) had a valuable paper on syphilis of the lungs, and discussed the relation of such dis- eases to hereditary syphilis. Gamberini (1880) made some excellent clinical studies in syphilitic diseases of the lungs. Von Cube's report contains a great deal of new matter. Lehmann (1881) had an interesting paper on the same subject. Sailer ( 1881 ) reported two cases of pulmonary syph- ilis. Rutgers von den Loef reported several interesting cases. Schech (1881) made the literature interesting by his reports. Pancritius ( 1881 ) published his work on the practical treatment of syphilitic diseases of the lungs. Engstrom, too, has practi- cal and useful hints on the treatment of syphilis of the lung. Schech (1882) published a paper on syphilis of the lung and trachea. Rodriguez Gongora (1882) reported on methods of treatment. The year 1882 was prolific in papers and reports on this subject. Carlier's study upon pulmonary syphilis; Con- cetti's case ; and Hiller's two cases, are all important contribu- tions. Engel (1882) was the first to differentiate pulmonary 414 THE SURGERY OF THE LUNGS syphilis from tuberculous phthisis, or rather, to give a method of differential diagnosis in cases of syphilitic diseases of the lung. He also has some valuable remarks upon the pathology of the lungs in this disease. Guntz (1882) published a valu- able paper on diagnosis by examination of the sputum. The next year, 1883, is also prolific in reports, papers, etc., on this subject. Raphael. Senger, Blondeau, De Renzi, and Nogueire each have published cases that came under their ob- servation. Rethi (1884) reported methods of treatment. Koeniger, Kopp, De Renzi, Hiller, and Juarez with his paper on lung troubles in children, caused by syphilis, made lasting contribu- tions to medical literature upon this subject. The year 1885 was not the least prolific in papers and re- ports on lung syphilis, as witness : Porter, Signorini, Ferguson, and the valuable article in the Boston Medical and Surgical Journal. Wt are again placed under obligation to Schnitzler for his paper on the pathology of pulmonary syphilis, etc. Both Bruen's remarks and Augier's and Laveran's papers are valu- able. Szohner's paper (1886) on syphilitic cirrhosis of the lung and mode of treatment was valuable. Heler (1886-87) pub- lished papers on this subject. Karnbach (1887) appeared with a valuable work on the pathology of syphilis of the lung. Mauriac (1888) reported a case of tertiary syphilis of the lung, and Ruhemann added to our knowledge of the treatment of this class of disease. Beissel's paper ( 1886) also proved of value because he details his experience in diagnosticating cases of syphilis of the lung. Potain's work on the history, cause, pathological anatomy, symptoms, and diagnosis of pulmonary syphilis is of great value. De Blois (1889) published an interesting paper on the manifestations of syphilis of the upper air passages. Haslund ( 1890) reported cases of a similar character. Raymond ( 1890) SYPHILIS 415 wrote a most interesting work on the results of experiments on animals, regarding tertiary syphilis, and its effects on the lungs, larynx, trachea, and bronchus; also bronchopneumonia, and adenopathic pleurisy; the peritracheal compression of the right recurrent nerve, and miliary aneurysm, due to syphilis. Bokenko (1890) reported a case in which the left lung was affected, and at the same time the patient had an attack of ca- tarrhal pneumonia of the right lung. Kurn (1890) reported a case of pulmonary syphilis. Forget (1890) reported a case, complicated with adeno- pathic tracheobronchitis. Lancereaux (1891) published a work on the various pathological changes produced in the lung by syphilis. Councilman (1891) and De Renzi reported cases of pulmonary syphilis. Perry (1890-91) reported a case of diffuse syphilitic fibroma of the lung. Neeman reported a case of multiple gummata, and Rolleston (1890-91) reported a similar case. Satterthwaite (1891) published a treatise on pulmonary syphilis in the adult. Sevestre (1891) had a case of pneumo- thorax in an infant, twenty-two months old, due, probably, to syphilis, and Roublefif added his contribution to the study of syphilitic affections of the lungs. Manfan (1892) reported cases and De Renzi (1892) pub- lished a most interesting case of pulmonary syphilis. Seibert (1892) brought out a paper on syphilitic bronchiostenosis in children. Hodenpyl's article on the differential diagnosis of miliary tuberculosis and gummata in the same lung, is of great value, and Juleos's work on the diagnosis and treatment of pulmonary syphilis is also timely and valuable. Abrams (1893) reported the results of an autopsy, held in a case of death from syphilis of the lung. Feulard had a case of syphilis, and gummata of the right lung simulating gangrene and tuberculosis. His treatment is of great interest. Peterson and Thompson ( 1893) reported cases which they had treated. Bryson published a 4l6 THE SURGERY OF THE LUNGS paper on some of the manifestations of syphilis of the upper air passages. Schirren and Gerber's reports (1894) were on cases of hereditary syphiHs of the lungs. Gemmell had a very interest- ing case of syphilitic ulceration of the trachea and bronchia, with fibroid induration of caseous tuberculous nodules in the basal parts of the lungs, with enlargement of the lymphatic glands and gummata in the liver. Those interested in this sub- ject will find many useful hints in Le Fevre's work on the value of early diagnosis in syphilitic lesions of the upper respiratory tract. Straight (1894) had a case of pulmonary syphilis, compli- cated with catarrh of the apex. Pispoli ( 1895) reported a very interesting case. Merigot de Treigny (1896) published a valuable paper on pulmonary syphilis, and Tandoff's paper on the same subject is of some value. The same may be said of Vires's paper. Schwyzer has some useful and valuable data on the treatment, especially the surgical treatment, of cases of syphilis of the lungs. Lucidi has made a contribution to the literature on this subject. Potain's paper on the connection of alcoholism and pul- monary syphilis is of great value, while Mongour's case has some points worth considering. Taube (1897) writes on the treatment and Carruccio (1897) reported cases of pulmonary syphilis. Dinkier (1898) published a paper on the manifesta- tion of syphilis in the upper respiratory tract, with a report of a case of chancre of the nasal saiptum. Dieulafoy ( 1898) pub- lished a paper on syphilis of the pleura, lungs and bronchia. Fowler (1898) published an interesting work on syphilitic dis- eases of the lungs. At the Ninth German Medical Congress, April, 1901, Hausemann exhibited three cases of syphilis of the lungs. He spoke of the difficulty of differentiating syphilis of the lungs from tuberculosis. Plate LXIII. Posterior View of Transverse Section of the Lungs. (Description, page 486.) SYPHILIS 417 BIBLIOGRAPHY Zadig, /. D. Pract. Arznk. u. Wundarank, Jena, 1797, IV, 478. MuNK, London Medical Gazette, 1841, XXVII, H, 179, 218. Langnean, Paris, 1851. Stevenart, Presse Med. Beige, Bruxelles, 1853, V, 113-115. AiTKEN, Army Med, Dept. Rept., 1861, London, 1863, 432-441. Wagoner, Archiv der Heilkunde, IV, p. 222 1863. FoNTAiN, Mem. et Compt. Rend. Soc. de Sc. Med. de Lyons, 1865- 66, V, 27c^275. Verneuil, Union Med., No. 29, p. 462, 1866. Meschede, Arch. j. Path. Anat., etc., Berlin, 1866, XXXVII, 565-567- Gintrac, Mem. et Bull. Soc. Med.-Chir. d. Hop. de Bordeaux, 1867, II, 295-302. Gerhardt, Deutsche Archiv }. Klin. Med., Vol. II, p. 541, 1867. Negri, Milano, 1868. OuvRE, Norsk. Mag. /. Laegevihensk, Christiana, 1870, XXIV, 359-365- LiNDSETH, Norsk. Mag. f. Laegevidensk, Christiana, 1870. Depaul, Bull. Soc. de Chir., Paris, (1869) 1870, 2 s., X, 434, 436. Fox, Reynolds' System of Medicine, London, 1871, Vol. Ill, pp. 792-799. Zelinski, Botok. zasaid. Kavkazsk. Med. Ohrsh., Tiflis, 1871, VIII, 12. Kelly, Transactions Path., Society, Vol. XXIII, 1872. HucHARD, Bull. Soc. Anat., Paris (1871), 1873, XL VI, 207. GooDHEART, Trans. Path. Soc, London, 1873-74, XXV, 31-33. Grandidier, Berlin. Klin. Woch., 1875, XII, 195-197. RoLLiTT, Wien. Med. Presse, 1875, XVI, 1101-1105. FouRNiER, Gaz. Hebd. de Med., Paris, 1875, 2 s., XII, 758-802. Pentinalli, Movimento Med.-Chir., Napoli, 1876, VIII, 513-554- 1877, IX, 36-49-65. Frey, Allg. Med. CenlrlM. Ztg., Berlin, 1876, XLV, 641. Mahomed, Trans. Path. Soc, London, 1876-77, XXVIII, 339-342. 4l8 THE SURGERY OF THE LUNCS GowERS, Trans. Path, Soc, London, 1876-77, XXVIII, 330. De Bomilla, Ahserriador Med., Mexico, 1876-77, IV, 210-221. Pye-Smith, Trans. Path. Soc. of London, Vol. XXVIII, p. 334, 1877. Porter, Trans. Med. Assn. Missouri, St. Louis, 1877, XI, 48-54. Poggio-Gac, de Samid. Mir., Madrid, 1877, III, 229-393. Tiffany, Am. Jour. Med. Sc, Philadelphia, 1877, LXXIV, 90-95- Jaunuzzi, Spallanzani, Moderna, 1877, XV, 410-424. Landrieux, Paris, 1878. ViERLiNG, Deut. Arch. f. Klin. Med., Leipzig, 1878, XXI, 325-347. KoRTUM, Regensburg, 1878. Hand, Trans. Minn. Med. Soc, Minneapolis, 1878, 11 2-1 14. Proksch, Wien. Med. BL, 1879, 1167-1189. Warder, Tr. Path. Soc. Philadelphia (1877-78), 1879, VIII, 101-106. Langerhaus, Arch. }. Path. Anat., Berlin, 1879, LXXV, 184. Eve, Wie7i. Med. Presse, 1879, XX, 780. ScHNiTZLER, Wien. Med. Presse, 1879, ^^> 329> 433> 47i> 601, 665, 873, 1027, 1061, 1081, 1113, 1204, 1297. Sacharjiss, Arch. }. Path. Anat., etc., Berlin, LXXV, 162-176. Henop, D., Arch. }. Klin. Med., Leipzig, 1879, XXIV, 250-253. ScHNiTZLER, Vienna, 1880. Cantarano, Gior. Internaz. d. Sc. Med., Napoli, 1880, II, 857-864. EwART, Transactions Path. Soc, 1880. Frank, Wien. Med. Presse, 1880, XXI, 1204. Gamberini, Gior. Internaz. d. Sc. Med., Napoli, 1880, II, 521. VON Cube, Arch. f. Path. Anat., etc., Berlin, 1880, LXXXII, 516- 528. Lehmann, Biblioth. }. Laegcr. Kjobenk., 1881, XI, 421-472. Seiler, Med. and Surg. Reporter, Philadelphia, 1881, XLIV, 427. Rutgers, Nederl. Mil. Geneesk. Arch., etc., Utrecht, 1881, V, 426-446. ScHECH, Aerztl. Int. BL, Miinchen, 1881, XXVIII, 463-466. Pancritius, Berlin, 1881. SYPHILIS 419 Engstrom, Finska laksallsk, HandL, Helsingsfors, 1881, XXIIl, 137-139- Rodriguez, Cron. Med. quir. de la Habana, 1881, VIII, 308-310. ScHECH, Deut. Arch. }. Klin. Med., Leipzig, 1882, XXXI, 410-420. Carlier, Paris, 1882. Concetti, Bull, de Soc. Lancisiana d. Hosp. di Roma, 1882, II, 16-19. HiLLER, Charite Ann. (1880), Berlin, 1882, VII, 349. Engel, Philadelphia Medical Times, 1882-83, XIII, 4-7. GuNTZ, Memorah. Heilbr., 1882, N. F., II, 203-214. Kopp, Deut. Arch. /. Klin. Med., 1883, Vol. XXXII, p. 305. Raphael, New York Medical Journal, 1883, XXXVII, 571-574. Senger, Berlin, 1883. Blondeau, France M^d., Paris, 1883, II, 829-831. De Renzi, Riv. Clin, e terap., Napoli, 1883, V, 465. Nogueire Jaguaribe, Rio Janeiro, 1883. Rethi, Wien, Med. Presse, 1884, XXV, 1655-59. KoENiGER, Deutsche Med. Wochenschr., Berlin, 1884, X, 816. Kopp, Arb. A. d. Med. Klin. Inst. d. k. Ludwig-Maximilians Univ. zu Miinchen, Leipzig, 1884, I, 333-344. De Renzi, Bull. d. Clin., Napoli, 1884, I, 313-316. Juarez, Amtl. Ber. u. d. Versaummel deutsch. Naturfp. u. Aerzte, 1883, Frieb. i. Br., 1884, LVI, 249-251. HiLLER, Charite Ann. (1882), 1884, IX, 184-282. Porter, W. H., New York Medical Journal, 1885, XLI, 139. Boston Medical and Surgical Journal, 1885, CXII, 397-401. SiGNORiNi, Firenze, 1885, LVI, 260-264. Ferguson, Medical News, Philadelphia, 1885, XL VI, 66-69. Schnitzler, Wien. Med. Presse, 1886, XXVII, 465-544. Bruen, Medical News, Philadelphia, 1886, XL VIII, 317-321. AuGiER AND Laveran, Joumal d. Sc. Med. de Lille, 1886, VIII, 345-354- SiLCOCK, Trans. Path. Soc, Vol. XXXVII, p. 100, 1886. SzoHNER, Gyogydszat, Budapest, 1886, XXVI, 369-374; Internat. d. Sc. Med. Cocpt. Rend., 1884; Copenhagen, 1886, I, Sect' de Path. Gen., etc., 108-110. 420 THE SURGERY OF THE LUNGS Heler, Deut. Arch. }. Klin. Med., Leipzig. XLIII, 159-174. Karnbach, Halle, 1887, ScHECH, Intern. Klin. Rundschau, 1887. Mauriac, Gaz. d. Hop., Paris, 1888, LXI, 414, 444, 499, 573, 622, 644. RuHEMANN, Internat. Klin. Rund., Wien, 1888, II, 439, 471, 521. Beissel, Internat. Klin. Rund., Wien, 1888, II, 1567, 1612, 1649. PoTAiN, Gaz. d. Hop., Paris, 1888, LXI, 1265-1313. PoTAiN, France Med., Paris, 1889, I, 301-304. GuLLiON, Trans. Path. Soc., Vol. XL, 1889. De Blois, New York Medical Journal, 1889, I, 510-513. Haslund, Hosp. Tid. Kjohenh., 1890, s. r., VIII, 173-397. Raymond, Gaz. d. Hop., Paris, 1890, LXIII, 613-16. BoBENKO, Objazat. pto-anat. izslied stud. med. Lp, Charkov Univ., 1890, 218-225. KuRN, Gyogyaszat, Budapest, 1890, XXX, 232. Forget, Bordeaux, 1890, No. 54. De Renzi, Rev. Clin. d. Univ. di Napoli, 1890, XI, 83-91. Perry, Trans. Path. Soc, London, 1890-91, XLIII, 83. Neeman, Proc. New York Path. Soc, 1890-91, 82. RoLLESTON, Trans. Path. Soc, London, 1890-91, XLII, 50-53. Lancereaux, Union Med., Paris, 1891, 3 s., LI, 145-161. Councilman, Johns Hopkins Hosp. Bull., 1891, II, 34-37- Saterthwaithe, Boston Medical and Surgical Journal, 1891, CXXIV, 573-600. Sevestre, Rev. Mens. Mai. d. PEn}. Paris, 1891, IX, 260-268. Kernig, Petersburg Med. Wochenschr., Vol. XVIII, 1891. RouBLEFF, Paris, 1891, No. 334. Favraud, Jour, de Med. de Bordeaux, May 31, 1891. Manfan, Gaz. d. Hop., Paris, 1892, LXV, 29-37. SoMURRA, Arch. Internaz. d. Spec. Med.-Chir., Napoli, 1892, VIII, 121-127. De Renzi, Morgagni, Milano, 1892, XXXIV, 337. Seibert, Arch. Pcediat., New York, 1892, IX, 830-839. Hodenpyl, Med. Rec, New York, 1892, XLIII, 659. JuLiES, Union Medicale, Paris, 1893, 3 s., LV, 565-68. Plate LXIV. Experiment ox Luxgs, Xo. 4, page 487. SYPHILIS 421 JuLiES, Ann. de Dermatol, et Syph., Paris, 1893, 3^-i IV , 450-455. Abrams, Occidental Med. Times, Sacramento, 1893, VII, 365-366. Feulard, Bull. Soc. Frangaise de Dermatol, et Syph., Paris, 1893 IV, 285-287. Peterson, Munch. Med. Wochenschr., 1893, 725-727. Thompson, Med. Rec, New York, 1893, XLIV, 522. Bryson, New York Med. Journal, 1893, LVIII, 727. ScHiRREN, Dermatol. Ztschr., Berlin, 1894, I, 221-225, Gerber, Eine klinische Studie, Wien u. Leipzig, 1894. Gemmell, Glasgow Med. Journal, 1894, XLII, 107-114. Le Fevre, Kansas Med. Jour., Topeka, 1894, 429-434. Straight, Medical News, Philadelphia, 1894, LXV, 600-602. PisPOLi, Gior. Med. d. r. Esercito, etc. Roma, 1895, XLIII, 1241-1250. Tandoff, Med. Ohozr. Mosk., 1895, XLIII, 530. Vires, Gaz. d. Hop., Paris, 1895, LXXIII, 965-973. Merigot de Treigny, Rev. Gen. de Clin, et Therap., Paris, 1896 X, 84-86. Schwyzer, Miinch. Med. Wochenschr., 1896, XLIII, 337. HoBBS ET Broustet, Jour. de Med., Bordeaux, 1896, XXVI, 368 LuciDi, Rossogna Med., Bologna, 1896, IV, No. 10, 1-5. PoTAiN, Jour, de Med. et Chir. Prat., Paris, 1896, LXVII, 726-729. MoNGOUR, Jour, de Med., Bordeaux, 1897, XXVII, 181-184. Taube, St. Petersburg Med. Wochenschr., 1897, N. F., XIV, 376- 378. Carruccio, Policlin., Roma, 1897, IV, M., 382-396; Munch. Med. Wochenschr., 1898, XL VIII, 1-7 (Dinkier). Kenefick, Medical News, New York, 1898, LXXII, 266-268. DiEULAFOY, Independ. Med., Paris, 1898, IV, 353. Fowler, System of Medicine (AUbutt), New York and London, 1898, V, 311-332. Graham, Chambers, Dominion Medical Journal, September, 1902; Virchow's Arch., Vol. XV, p. 310. CHAPTER XVI BENIGN TUMORS— LYMPHOMA, CHONDROMA, OSTEOMA, DERMOID TUMORS It has been thought best to make but three divisions in the classification of tumors, i.e., Benign Tumors, MaHgnant Tumors, and Parasitic Tumors. Historical — Virchow (1863) was the first to make a satis- factory classification of tumors, in recognizing a homology and a heterology in new growths, even though a homologous growth may become heterologous. It has been only in the last decade that certain forms of be- nign tumors have been observed. Schultz {Russk. Med., St. Peter sb., 1890, xvi., 518-524) reports a case of primary fibroma in the lung of a child two years of age. Moskowitz (Gyn- ogyszat, Budapest, 1891, xxxi, 317-329) had a case of scle- roma of the air passages. Poor (Lond. Lancet, 1895, ^' ^7Z) reported a case of tumor of the lung; while ZakiefT (Roussky Vratch, St. Peters., 1897, xviii., 340-342) reported four cases of tumor of the lung. West. (St. Barth. Hosp. Reports, 1897, Lond., 1898, xxxiii., 109-137) reported cases of new growths of lung and pleura. LYMPHOMA — Lymphoma, pseudoleucsemia, or Hodgkin's disease, is a rare malignant growth, resembling sarcoma, that sometimes attacks the lungs. It is generally secondary to pri- mary involvement in the cervical glands, that is, other than bronchial glands are involved. It usually follows the glands of the bronchia, and fills the lungs from their base by involving the interlobular saepta. It is a formation of lymph tissue as a 422 LYMniOMA — CHONDROMA, OSTEOMA, DERMOID TUMORS 423 diffused infiltration of lung tissue, and should, therefore, be classed with sarcoma. The lymphoid cells are supported in a delicate reticulum of a hard and soft variety. More or less fluid may be present, and it may be gray or white in color, with no distinction between the cortical and medullary portions. The cells are greatly in- creased in number. The harder growths are yellowish white and dry, rarely spreading beyond the capsule, and never under- going cheesy degeneration. Suppuration is rare. The capsule is thickened with fibrous bands which pass through the mass. It is found oftener in men than in women, the ratio being three to four. The lungs of the cobalt miners of Schneeberg are said to be invariably affected with lymphosarcoma. CHONDROMA — Chondromata usually appear in cartilage (enchondromata), but may originate in the absence of cartilage (ecchondromata). In the lung, however, its origin appears to be in the bronchia. Ecchondromata are rare, but enchondromata are not so rare. The latter may be composed of hyaline cartilage, fibrocartilage, or osteoid tissue. They may be soft, or, partially or com- pletely ossified. Chondromata are often the result of trauma, and may be combined with sarcoma. The case of primary en- chondroma reported by Courment gives such a history. (Lyon Med., 1895, Ixxviii., pp. 259-261). OSTEOMA — There are three varieties of tumors formed of osseous tissue, i.e.. Osteoma durum or eburneum ; Osteoma spongiosum; Osteoma medullosum. The first is formed of exceedingly hard tissue which resembles the cement substance of the teeth. The second is formed of spongy bone-tissue, with narrow trabeculse, and wide medullary spaces. The third has medullary spaces filled with marrow. All the osteomata agree, structurally, with normal bone-tissue in the main points, but differ in not having the regular architecture of the bone tra- beculse, and in not having the typical arrangement of the vascu- lar and medullary canals and bone-corpuscles. 424 THE SURGERY OF THE LUNGS The osseous and cartilaginous tumors are said to be more frequent in youth, but do not appear in young children. They are also more frequent in men than in women. Osteomata are frequently found in the lung in the form of thin plates. They are of very slow growth. Some writers think there is a heredi- tary disposition to these growths, especially for the mutiple variety. Osteomata in the lungs are supposed to be due to syphilis, or gout. They do not often reveal their presence during life; they are usually found on autopsy. The removal of osteomata is to be considered only when they become troublesome ; doubt always prevailing as to their charac- ter before exposure of the lung, prior to, or, after death. When surgical intervention is employed, they should be removed in the same manner as other foreign bodies, or benign tumors. Brambella (Gac::. Med. Lomb., Milan, 1895, liv., 128- 130) reported a case of multiple osteoma of the lung which was, perhaps, due to gout or syphilis, the history of injury being absent. DERMOIDS may be found in one or both lungs, but usually, in one only. They are rare, however, and are found, as a rule, on autopsy. Their variety is shown by the few cases reported. Goodlee opened a dermoid cyst of the lung, removed the processes and drained with recovery {Trans. Mcd.-Chir. Soc, 1889). Sormain of Milan mentions a case of dermoid cyst {Gazz. d'Osp., Milan, 1890, xi., 314-332). Ogle also described in detail a dermoid growth in the lung {Trans. Path. Soc, Lond., 1896-97, xlviii., 37-39). The amount and character of dermoid tissue in the lung varies, as it does in other organs of the body. Included in this group are the following four rare growths : Lymphoma, Chondroma. Osteoma, and Dermoids. Lymphomata are the most treacherous of this class owing to their sarcomatous characteristics. The remaining three are harmless, unless their growth should be continuous, when the Plate LXV. ipf3t_..W<.^ Experiment un Lungs, Xo. 6, page 488. LYMl'llOiMA— CHONDROMA, OSTEOMA, DERMOID TUMORS 425 danger would be due to increased size. They would then act mechanically. But this is a rare occurrence, especially in the lungs. All benign neoplasms, as a rule, seem to be limited in growth in the lungs. Treatment. — Lyinphomata should be dealt with in as radi- cal a way as sarcomata and in the same manner. Chondrouiata, because of their position at or near the base of the lung, almost preclude the possibility of attack. Not so, however, with the osteomata. These are usually numerous small bodies located here and there in the parenchyma. Their removal offers little hope of success, as the bodies are too small to justify search for them. If, however, an osteoma should be large enough to be detected with the finger, or otherwise, its removal should be accomplished. The detection of dermoid cysts is also very difficult. Gen- erally, they are small, but when detected they should be incised and their contents removed through the chest wall. Dissection of the tumor capsule is not necessary, as the cavity can be treated much in the same manner as in the removal of other growths. In conclusion it may be said that a benign tumor requires no interference, except when troublesome on account of size. A malignant tumor cannot be entirely removed. CHAPTER XVII MALIGNANT TUMORS— SARCOMA, CARCINOMA There having been numerous reports of malignant growths of the hmg before a classification of malignant tumors had been made, it is necessary to consider " cancer " as then used to be a general term covering all malignant growths. Historical (1833-1903). — Bricheteau's work published in 1833 has some suggestive things bearing on this subject. It reported a doubtful case of the lungs, with irreducible omental hernia. Begbie (i860) had a case of mediastinal and pulmo- nary cancer, attended by great local dropsy. Russell (1869) reported a case of primary cancer of the lung, simulating pleu- ritic effusion. Experimental paracentesis was done. Moore ( 1890) reported a new growth in the mediastinal gland and left lung, in a boy aged ten years. Schwable ( 1891) published his hand-book on cancer of the lung. Spillman and Haushalter ( 1891 ) published a paper on the diagnosis of malignant tumors in the lungs. Satterwaithe (1891-92) reported rare pulmonary growths. Leprevost ( 1892) reported a case of cancer of the left lung in a peasant. The lung weighed eight kilogrammes, and the cancer finally invaded the abdominal cavity. Powell ( 1892) reported a case of malignant disease invading the right lung, compli- cated w'ith gastric ulcer. Drysdale (1892) also reported a case of cancer of the left lung. Jappa reported an exactly sim- ilar case. Leech ( 1892) had a case of cancer of the lung, ter- minating in softening and cavity, and complicated with paren- 426 MALIGNANT TUMORS — CANCER, SARCOMA, CARCINOMA 427 chymatous nephritis. Inurrigarre ( 1892) had a case of malig- nant tumor complicated with pleuropneumonia. Jepha ( 1892) reported a case of primary lung cancer. Anderson ( 1893) had a case of cancer of the lung complicated with secondary cancer of the liver. Siegert (1893) published a paper on the histo- genesis of primary lung cancer. Passow (1893) published a treatise on the differential di- agnosis of tumors of the lungs, and Steel (1894) gave a clinical lecture on a case. Foa (1894) also reported a case of haemo- thorax, and cancer of the lung. Betschart (1895) published his work on the diagnosis of malignant lung tumors by means of the sputum. About this time appeared several reports on primary cancer of the lungs, the reports of Loomis, and De Renzi on primary cancer of pleuritic form, and Meuner's case of cancer of the bronchus. Wolf ( 1895) ^^so reported a case of primary cancer. Alder (1896) published a paper on the diagnosis of malignant tumors of the lung. Kazem-Beck (1897) added much to this subject by his report of two cases of primary cancer of the lung, and one of cancer of the mediastinum. Lenhartz (1897) had a case of primary lung and pleural cancer. Simmonds ( 1898) produced a work on the histology of primary lung cancer and Lazarus (1898) also reported malignant tumors of the anterior mediastinum and lung. Kazem-Beck (1898) again reported two cases of primary lung cancer. Tubenthel (1898) published a paper on opera- tions for cancer of the lung. Guralanos (1898) contributed to the literature on this subject, his study of the operations for pneumothorax, and resection for cancer of the lung. Yappa and Pensuti (1898) also had papers on primary cancer of the lung, while Claisse (1899) placed the profession under obliga- tions by his paper on diagnosis. 428 THE SURGERY OF THE LUNGS BIBLIOGR.\PHY Bricheteau, Gaz. d. Hop. de Paris, 1833, VII, 281. Brixton, Cancer (?), Trans. Path, boc, London, 1855-56, VII, 7072. Begbie, Arch. Med., London, 1860-61, II, 145-151. Russell, Lancet, London, 1869, 1, 814. Moore, Laticel, London, 1890, II., 876. ScHWABLE, Med. Wochenschr., Leipsic, 1891, XVII, 1235-1238. Spillman and Haushalter, Hebd. de Med., Paris, 1891, 2 s., XVIII, 575-587. Satterwaithe, Post Graduate Journal, New York, 1891-92, VII, 125-129. Leprevost, Bull, et Mem. Soc. de Ch., Paris, 1892, n. s., XVIII, 115-117. PowTELL, Middlesex Hosp. Reports, 1892, London, 1894, 87. Drysdale, Med. Press and Circ, London, 1892, n. s., LIII, 528. Jappa, Bolnitsch Gaz., St. Petersburg, 1892, III, 153-183. Leech, Chronicle, Manchester, 1892, XVL, 178-184. Lntjrrigarro, Rev. Soc. Melargent, Buenos Aires, 1892, 1, 305-308. Jepha, Berlin, 1892, 30 p. .Ajstderson, Glasgow Med. Journal, 1893, XXXIX, 94-96. SiEGERT, Arch. }. Path. Anat., Berlin, 1893, CXXXIV, 287-318. Passow, Berhn, 1893, 37 p. Steel, Lancet, London, 1894, I, 388-390. FoA, Gior. d. r. Acad, di Med. di Torino, 1894, XLII, III. Sptllmann, Rev. Med. de I' Est, Nancy, 1894, XXVI, 705-711. Betschart, Path. Anat., Berlin, 1895, CXLII, 86-100. Looms, Med. Rec, New York, 1895, XL VIII, 167. De Renzi, Rev. Clin, e Terap., Napoli, 1895, XVII, 57. Meuner, Arch. Gen. de Med., Paris, 1895, I, 343-352. Wolf, Forisch. d. Med., Berlin, 1895, XIII, 725-765. Abler, New York Med. Jour., 1896, LXVIII, 173-204. Kazem-Beck, Med. Ohozr. Mask., 1897, XLVIII, 3-13. Lenhartz, Munch. Med. Wochenschr., 1897, 1488-1514. Plate LXVI. Exi'ERiAii£XT OX LuxGS, Xo. /. page 488. MALIGNANT TUMORS — CANCER, SARCOMA, CARCINOMA 429 SiMMONDS, Munch. Med. Wochenschr., 1898, 189. Lazarus, Berl. Klin. Wochenschr., 1898, 175. Kazem-Beck, Centrhl. /. Inn. Med., 1898, 281-290. TuBENTHEL, Deut. Med. Aerztl. Ztschr., 1898, XXVI, 552-559. Guralanos, Zeitschr. }. d. Chir., 1898, XLIX, 497-536. Yappa, Bolontsck. Gaz. Botkino, St. Petersburg, 1898, XIX, 927- 930- Pensuti, Gaz. d'Osp., Milano, 1898, XIX, 1576. TucHENDLER, Medjcyna Warszawa, 1898, XXVI, 715-717. Claisse, Bull, et mem. Soc. Med. d. Hop., Paris, 1899, XVI, 46-49. Schmidt, M., Zur casuistik des primaren lungenkrebs Inaug-Diss., Jena, 1900, Feb. Chrisditis a.. Contribution a I'etude des symptomes et du dia- gnostic du cancer primitif du poumon. Rev. Med.-Pharm., Constant, 1900, XIII, 74-78. Gueldre, Du Cancer generalise des deux poumons; autopsie. Ann. et Bull. Soc. de Med. d'Anvers, 1900, LXII, 83-89. GuTTMANN, J., Consideratinni aspura cancerului pulmoner. Spi- talul. Bacuresci, 1900, XX, 226-240. Geisler, T. K., Lefons cliniques d'un cas de cancer primitif du poumon. Vratch, St. Petersburg, 1901, XXII, 729-732. Olmer, Tuberculose, et cancer primitif du poumon, Marseille Med. 1901, XXXVIII, 279-284. Sarda et Oulie, Un cas de cancer primitif du poumon. Echo Med., Toulouse, 1901, XV, 265-266. Shaw, H. B., Brit. Med. Journal, London, 1901, I, 1331, 1333; 2 fig. RiSPAL, Cancer primitif du poumon. Echo Med., Toulouse, 1901, XV, 65-69. NicoLLE ET Halipre, Canccr secondaire du poumon (presenta- tion de pieces). Normandie Med., Rouen, 1902, XVIII, 163- 164. SARCOMA. — While rare, sarcoma is said to be the most common of the malignant growths of the lung. It may be of primary or secondary origin. When primary, it develops 430 THE SURGERY OF THE LUNGS from the larger bronchia, usually at, or near their base. The de- velopment is rapid, gradually involving the bronchial tract, and, subsequently, the lung tissue proper. Haemorrhage is rare, and when it does occur, is likely to be fatal. Historical (183 3- 1903). — The year 1890 saw the first pub- lished account of these tumors. Although the year previous Davies had reported a case of lymphosarcoma of the left lung, yet in 1890, Kozlowski and Marini reported cases in addition to that reported the same year in Berlin. Sangelli (1888) reported a case, but he seems to have been a little doubtful as to the diagnosis. Jackson (1890) also re- ported a case of secondary adenosarcoma of the lung, and Schech was another who appeared in print on the same subject. Vandervelde (1892) produced a paper on a case of primi- tive encephaloid sarcoma of the lung. Rolleston (1890) re- ported a case of myxosarcoma of the lung. Barclay (1892), Ferrand, and Mirinescu (1893), reported cases of sarcoma. West (1894) had a case of primary sarcoma of the lung in a boy aged eleven. Before this Ehrlich had reported a case of primary bronchial and lung sarcoma. Dolgopol discusses in a very interesting way the question of sarcomatosis of the internal organs, and also reports a case of sarcoma of the lung. Pack- ard reported a case and Sangalli's observations on sarcoma of the pleura and lungs are of great value. Greenwood reported a case of pulmonary sarcoma. Besson ( 1898) wrote a report of alveolar sarcoma, secondary to that of the pleura and lung, and Hooper, Milan, Habershon, have reports of cases of lympho- sarcoma. (For an interesting account of osteosarcoma of the lung see Berl. Klin. Woch., 1898, p 349.) Pathology — Sarcomata are characterized by possessing a large number of cells on a typical connective tissue. The cell structure of the sarcomata is similar to that of the granulation tissue of an old ulcer. At times large protoplasmic masses, containing many nuclei, may be found. The blood-vessels, which ramify through these tumors, appear to be nothing but Plate LXVII. ExpiiKiMENT ON LuNGS, No. 8, page 4S8. MALIGNANT TUMORS— CANCER, SARCOMA, CARCINOMA 43 1 channels, surrounded by a net-work of connective tissue. The small vessels are in direct contact with the tumor cells. They are more voluminous than blood-vessels in normal tissues. Their cell walls are often similar to the tumor cells. The sar- comata are classified according to the shape of their cells, and also according to the other kinds of tissue that may be found incorporated in the tumor. Shaw reports a case of stenosis of the bronchus and vessel, associated with pneumonia, produced by a sarcoma at the root of the left lung. There was great resemblance to tuberculosis, microscopically, but a more minute examination revealed the true state of affairs. BIBLIOGRAPHY Sangelli, ist Lomb. di so. e lett. Rendic, Milano, 1888; XXI, 662-8. Davtes, Trans, Path. Soc, London, 1888-89, ^I> 4^- HuBER, Ztsch. j. Klin. Med., Berlin, 1890, XVII, 341-352. KoziiDWSKi, Prog. Med., Paris, 1890, 2s., XI, 205. MartnTjDw. Internaz. d. Soc. Med. Napoli, 1890, n. s., XII, 98- 102. Jackson, Proc. New York Path. Soc, (1889) 1890, 107. ScHECH, Deut. Arch. }. Klin. Med., Leipsic, 1890-91, XL VII, 411- 416. Vandervelde, De MM les Profs. Sacre et Houze, Jour, de Med.- Chir. et Phar., Bruxelles, 1892, XCIV., 193-197. RoLLESTON, Trans. Path, Soc, London, 1890-91, XLIII, 54. Barclay, New Zealand Med. Journal, Dunedin, 1892, V, 170, Ferrand, Bull, et Mem. Soc. de Med. d. Hop. de Paris, 1893, X, 796. MiRiNESCU, Spitalul, Bucuresci, 1893, XIII, 401-403. West, Brit. Med. Jour., London, 1894, II, 532, Ehrlich, Marburg, 1891, 12 p. DOLGOPOL, Bolich Gaz. Boikina, St. Petersburg, 1895, VI, 676-680. Jacobsohn, Deut. Med. Ztg., Berlin, 1897, XVIII, 487. 432 THE SURGERY OF THE LUNGS Packard, Med. News, New York, 1897, LXXI, 329-333. Sangalli, Gaz. Med. Lomb., Milano, 1897, LVI, 225-235. Greenwood, Brit. Med. Journal, London, 1897, II, 1337. Besson, Jour. Sc. Med. de Lille, 1898, I, 68-72. Packard, Trans. Coll. Phys., Philadelphia, 1897, XIX, 145-148, Berlin. Klin. Woch., 1898, 349. Hooper, Intercol. Med. Journal, Melbourne, 1898, III, 222-224. Milan, Bull. Soc. Anat., Paris, 1898, LXXIII, 336-340. MoiSEYEFF, Bolnitsch. Gaz. Botkina, St. Petersburg, 1898, IX, 1631. Hebershon, Trans. Path. Soc, London, 1897-98, XLIX, 17-20. Burt, S.S., Multiple metastatic sarcomata of the lungs. Phila. Med. Journal, 1900, VI, 545-550; 4 fig. Mayer Paul, Beitrag zur casuistik der primaren lungensarkome. Inaug. Diss., Munchen, 1900, August and September. MiLiAN ET Maute, Sarcome primitif du poumon, Bull, et Mem. Soc. Anat., Paris, 1901, III, 82-84. Ferrari, C, Due casi di sarcoma del polmone con sintomi di para- lisi simpatica riflessa per compressione della parte inferiore del plesso brachiale in Albertoni (Pietro), Ricerche di Bio- logia, etc., Bologna, 1901, 363-372. BuiCLiu, A., Supra unui caz de sarcom pulmonar secundar, Spi- talul. Bucuresci, 1902, XXIII, 108-114. CARCINOMA — It is said that carcinoma is less common in the tropics than in the colder regions. Billings showed that it is more frequent in New England, New York, Ohio, Michigan, and the south Pacific; that it is less frequent in the Mississippi valley and southern coast, than in the interior. Carcinoma in the lung is less frequent than sarcoma, and slower in its development; both, however, develop more rapidly in the lung than in any other tissue of the body. Carcinoma may be primary or secondary in the lung. It is a malignant endothelial and epithelial growth, springing from the same embryonic tissue, which may be found in the sputum. Historical ( 1833- 1903). — Among the earliest reports is that MALIGNANT TUMORS — CANCER, SARCOMA, CARCINOMA 433 of the surgeon general of the Marine Hospital ( 1889). Wie- ber (1889) also reported a case of primary carcinoma of the lung with metastasis. Fuchs (1890) published an article on the treatment of carcinoma. In Berlin observations were made on a horse. Hardford ( 1889-90) reported a case of carcinoma of the root of the lung, with comparative absence of symptoms ; it was complicated with simple gastric ulcer, and death resulted from enteritis. Rickards (1891) had a case of carcinoma, at the root of the left lung, with extension through the outer vertebral fora- men, and compression and softening of the spinal cord. Sat- terwaithe, Belcher, and Kidd (1891) reported cases. Kidd's case was very interesting, one of mediastinal and pulmonary carcinoma, associated with retraction of the chest wall. Simon ( 1893) published a case of primary carcinoma of the lung with secondary deposits in the liver, brain, and scapula. Perinato also reports a case. Wolfe reported thirty-one cases of primary carcinoma of the lung in seven thousand necropsies ; there were twenty-seven men and four women, of whom the youngest was thirty-six and the oldest seventy. In jfive cases, the right lung was affected, in three cases, the left. The right bronchus was the seat of disease in thirteen cases, and the left bronchus in eight cases. In two cases, both bronchi were affected. In thirteen cases, there were tuberculous complications, and, more likely, metas- tasis in cases of bronchial origin. Hampeln (1897) gave an extended account of carcinoma, and Pfarmenstill (1897) published his observations on primary carcinoma. Scotti (1898) reported on diffuse pulmonary car- cinoma. Le Count reported a case of diffuse secondary carci- noma, confined to the lymph channels of both lungs. The ne- cropsy discovered many metastatic tumor nodules in various organs. The primary tumor was located near the pylorus. As the edge of the right pleura lies between the oesophagus and aorta, it is very probable that a carcinoma of the oesophagus 434 THE SURGERY OF THE LUNGS may extend to the right pleura, and thence to the right lung, and vice versa. Pathology — Carcinomata are formed of true epithelial cells ; but they grow in an irregular, atypical manner. This is due, some claim, to the difference in pressure exerted by the various kinds of tissue in which they grow. They are arranged in alveoli, the latter round, elongated, club-shaped, etc., and are formed of single cells in close contact, with no connective tissue between the alveoli. There is no essential difference in structure of the various kinds of carcinomata which originate in the surface epithelium ; the same may be said of those which have a glandular origin ; but between those of glandular origin and those formed in the surface epithelium there is sufficient difference to enable them to be classified. Still the difference is only in their microscop- ical appearance. Weinburger reported two cases of primary bronchial carci- noma. One resembled tuberculosis. A third case, in a young woman, was a lymphosarcoma of the mediastinum, which in- vaded the lung. (ZeitscJu'ift fi'ir Hcilkiinde, volume xxii, part 2, February, 1901.) Heidenhain of Worms (Ninth Ger- man Congress, April, 1901) reported a resection of a lung for the removal of a carcinoma ; later, because of bronchiectasis, he had to make longitudinal incisions in the bronchial tubes, to evacuate pus. The most usual intrathoracic cancer is the medullary or en- cephaloid. Infrequently, a scirrhous cancer may be thus situ- ated, and there are a few reports of colloid. Many malignant growths are metastatic in origin, especially those found in the lungs. Walshe claims that cancerous dis- eases of the testicle may be followed by pulmonary cancer. Le- bert says that duration of life is from one to two years, and in some cases several years. Symptoms. — Pain, cough, and expectoration, the latter be- coming mucopurulent, and sometimes presenting the appear- Plate LXVIII. ExpERiMEXT ON LuNGS, No. lo, page 489. MALIGNANT TUMORS — CANCER, SARCOMA, CARCINOMA 435 ance of currant jelly. This peculiar appearance of the sputum is somewhat diagnostic. There is dulness on percussion and the respiratory murmur is either suppressed or modified. Treatment. — Unfortunately the removal of such growths offers but little encouragement. Prognosis would, however, become more favorable if the neoplasms could be removed ear- lier in their development. This is hardly possible, owing to the lung being inaccessible without opening the chest wall, which is not justifiable until the destruction of the lung has become too far advanced for safety. Operative measures are especially undesirable if the origin of the growth is in a bronchial gland or the base of the lung. However, if the growth involves the apex of the lung, and its removal be made early, much encouragement may ensue. As in all other operations upon the lung, resection of one or more ribs is necessary at a point most convenient for attack. It is also desirable in this, as in the majority of lung operations, to have adhesions of the visceral to the parietal pleura. The removal of the diseased tissue with the knife, ligature, cautery, or otherwise should be followed by securing the bleeding vessels and smaller bronchia with ligature, or clamp, or both, with suf- ficient pressure with gauze packing to prevent bleeding and the escape of air. Drainage is more easily and perfectly accom- plished in all pathologic conditions involving the lower portion of the lung. If only one lobe be involved, complete removal of that lobe should be practised with thorough drainage by gauze. BIBLIOGRAPHY Report Sup. Surg. Gen., Marine Hosp., Washington, 1889; 314. WiEBER, Berlin, 1889, 32 p. FucHS, Leipzig, 1890, 24 p. Grammlkh, Ztschr. f. Vetermark, Berlin, 1890-91, II, 445-448. Rep. Sup. Surg. Gen. U. S. Marine Hosp., Washington, 1889- 90; XVIII, 202. 436 THE SURGERY OF THE LUNGS Hardford, Trans. Path. Soc, London, 1889-90, XLI, 37-40. Peabody, Med. Rec, New York, 1891, XXXIX, 438. RiCKARDS, Brit. Med. Jour.., London, 1891, II, 13. Satterwaithe, Med. Rec, New York, 1891, XL, 257-264. Belcher, Brooklyn Med. Jour., 1891, V, 703-707. Rep. Sup. Surg. Gen., Marine Hosp., Washington, XIX, 1890-91; 153. KiDD, Trans. Clin. Soc, London, 1891-92, XXV, 178-180. Simon, Birmingham Med. Rev., 1893; XXXIV, 81-85. Perinato, Rev. Veneta di Sc. Med., Venezia, 1893; XIX, 393-399- Wolfe, Deutsch. Med. Wochenschr., 1896, No. 11, p. 365. Hampeln, Ztschr. Klin. Med., 1897, XXXI, 247-259. Pfarmenstill, C. C. R., No. 38-15-17. Nord. Med. Ark., Stock- holm, 1897. ScoTTi, N. Riv. Clin. Therap., Napoli, 1898, I, 57-59. Sailer, Contrib. f. Wm. Pepper Lab. of Clin. Med., Philadelphia, 1900, 416-446; 2 p. Parascandolo, Arte Med., Napoli, 1900, II, 441-444, 461-466. Hay, Liverpool M.-Chir. Jour., 1901, XXI, 155-156. Lammerhirt, Inaug.-diss. Griefswald, 1901, Mai. Cloin, Prag. Med. Woch., 1901, XXVI, 275-276. DiNKLER, Verhandl. d. Deutsch Pati. Gesellsch., Berlin, 1901, III, 59-61. Le Count, Jour. Am. Med. Assn., Vol. XXXVI, p. 589, 1901. Delorme, Inaug.-diss., Jena, 1902, Januar. BoTTGER, Munchen Med. Wochenschr, 1902. XLIX, 272-273. CHAPTER XVIII BACILLI— BACILLUS ANTHRACIS, BACILLUS (EDEMATIS MALIGNI, BACILLUS AEROGENES CAPSULATUS, BACILLUS PNEUMONIA, BACILLUS TUBER- CULOSIS, BACILLUS TYPHOIDES ANTHRAX. — This disease is very frequent in Russia, Hun- gary, France, and Saxony, and it occurs as an epidemic in Si- beria, and India. It is only occasionally found in man or beast, in the United States. Historical ( 1850-1903). — Bacillus anthracis was discovered by Davaine and Rayer, who reported to the Academic des Sci- ences (1850) the finding of small filiform bodies in blood in length about twice the diameter of a red blood corpuscle. Grouin states that fifty-six thousand cattle died of this disease in Novgorod, Russia, between the years 1867 and 1870. Among the domesticated animals, cows, sheep, and horses are more susceptible than asses, goats, and hogs. Mice, rab- bits, and guinea-pigs are especially susceptible to infection. It is difficult to infect dogs and poultry. Bacillus anthracis was the first to be discovered and is, therefore, of great interest, because it was the foundation upon which the science of bacteriology has been built. Pasteur suc- ceeded Davaine in the study of this bacillus, but the discovery of spores was not made until Koch reproduced the disease by inoculating animals. It was he who maintained that an infec- tion could take place through the organs of respiration ; he had placed a mouse under a bell-jar containing the bacilli, with fatal results. 437 438 THE SURGERY OF THE LUNGS The period of incubation is from a few hours to three or four days. Schottmuller (1898) reported two cases of anthrax in the lung. One of the patients was a maker of baskets from strips of hide ; in the other case the cause could not be ascertained. All those who work among cattle, sheep, wool, hides, etc., are exposed to infection. The domesticated animals, indige- nous to Algeria, seem to possess immunity from this dreaded disease. Salines in the soil, combined with warmth and mois- ture, are supposed to favor the development of the bacillus, hence the disease is prevalent along rivers and low lands. Symptoms. — Onset sudden ; dyspnoea ; headache ; chill ; fever ; nausea ; gastralgia ; coryza ; lacrymation ; exhaustion ; consoli- dation of lung; temperature, later on, sub-normal; sputum, al- though often like prune juice, is not characteristic. The out- come of the disease is very uncertain. BACILLUS (EDEMATIS MALIGNI Previous to Lister's great discovery, this organism caused many deaths from pro- gressive gangrenous oedema and emphysema. Its habitat is decaying matter, dust of dwellings, old rags, hay, etc. It is often associated with the bacillus tetanus in earth which has been fertilized with foul faecal matter. Rich garden earth has been used to inoculate animals by being in- jected, subcutaneously. The internal organs are only slightly affected by this ba- cillus. But the bacilli are found on all serous surfaces. It makes its appearance in the blood only after death. This bacillus resembles the bacillus anthracis. The colonies have a granular appearance. They form long chains which are often twisted. They have no independent motion. Spores are found in individual bacilli, but not in threads. It is anaerobic. (See chapter on CEdema, for a fuller description of this disease, etc.) BACILLUS AEROGENES CAPSULATUS (Gas Bacillus) The bacillus aerogenes capsulatus, described by several investigators Plate LXIX. Experiment on Lungs, No. ii, page 489. BACILLI 439 (see bibliography), is probably the cause of emphysematous gangrene in the lung as elsewhere. Although found most fre- quently in cases of trauma, it also has been observed in non- traumatic cases. Ohlmacher says that this bacillus " was not found in smears or cultures of the heart's blood, but it was found after inocula- tion of heart's blood into rabbits, which were killed and in twenty-four hours presented the characteristic lesions. An organism corresponding morphologically and tinctorially with the gas bacillus was found in the heart muscle, lung, kidney, and liver. In all of these, gas bubbles were also found on microscopic examination. Cultures from the heart's blood showed Staphylococcus aureus. Streptococcus pyogenes and the colon bacillus." {Amer. Medicine, July 27th, 1901, vol. ii, p. 137- ) Loeb, in the same article, states that " the bacillus of malig- nant cedema rarely, if ever, produces those lesions which were always attributed to it." " The bacillus aerogenes capsulatus, or Bacillus Welchii, practically dominates the whole field of pneumatopathology. " This organism is extremely virulent, but there is great variation in its action. One-half of the sixty reported cases of emphysematous gangrene, caused by the gas bacillus, have been fatal. The majority of the other half have either been mild, or recovery quickly ensued upon an operation. Even in severe cases, if the patient lives, the bacillus will die in ten days or two weeks. Mild cases have been known to recover sponta- neously. This bacillus gains a foothold in healthy tissue only with the greatest difficulty. The intestine is also one of the habitats of the gas bacillus, but thus it usually does little harm except in case of typhoid perforation, appendicitis, or strangulation. In some cases gas is not found in the tissues until after death ; again, there are cases in which the tissues do not produce gas. The bacillus aerogenes capsulatus is large and thick, and is 440 THE SURGERY OF THE LUNGS one of the encapsulated bacilli. It is not very active, but it has not been decided whether it is motile or not. It is supposed to be anaerobic. BIBLIOGRAPHY (Bacillus aerogenes capsulatus.) Bulletin oj Johns Hopkins Hosp., 1892, Vol. Ill, pp. 81-91. Annals 0} Surgery, 1894, Vol. XIX; pp. 187-196. Centralhlatt }ur Bakteriologie, 1893, ^^^- XIII, pp. 13-16. Bulletin oj Johns Hopkins Hosp., 1897, Vol. VIII, pp. 24-28. Progressive Medicine, December, 1899. Boston Med. and Surg. Jour., 1900, Vol. CXLIII, pp. 73-87. BACILLUS PNEUMONIA — Pneumonococcus (Friedlaen- der) is found in the alveolar exudate, and in the exudates from the pleura, and pericardium, in cases of croupous pneumonia. It has been found in the rusty sputum and blood. It is not a reliable diagnostic test, as there are other bacilli which resemble it, and because other varieties of bacilli also cause pneumonia. This bacillus is short and thick, somewhat resembling cocci. It is enveloped in a gelatinous capsule, sometimes a single cap- sule containing two or more bacilli. It has no independent mo- tion. The colonies are white, with knob-like projections above the surface. BACILLUS TUBERCULOSIS is the active cause of tuber- culosis, lupus, and scrofula. No animal seems to have absolute immunity from the ravages caused by this organism. All the diseases attributable to this bacillus can only be caused by infection with the bacilli, or their spores. Infection is by inhalation, by swallowing the virus, and by inoculation. The bacilli are found where the disease is just beginning to attack a new place. In the early stages of the disease, the ba- cilli are isolated, and will be found in the cells close to the nuclei ; where the disease has existed longer, the bacilli will be Plate LXX. Experiment on Lungs, No. 13, page 489. BACILLI 441 found in clumps. They are not readily found in old cheesy masses, unless the latter have been exposed to the air. They may always be found in the giant cells. The bacilli are often curved, or bent at an angle. The spores are larger in diameter than the individual bacilli. When found, from two to six will be seen together, BACILLUS TYPHOIDES (Eberth) was found in an abscess of the lung by Ramsey (1890, Annals of Surgery, January, p. 39). He also found it in a case of gangrene of the lung and spleen. It is probably of secondary and not primary origin, and when found, is associated with tissue necrosis, arising after the third week from the onset of the fever. CHAPTER XIX PARASITIC FUNGI— ACTINOMYCES, ASPERGILLUS, PNEUMONOMYCES, OIDIUM ACTINOMYCOSIS. — Actinomyces is a vegetable parasite found in animal and human life, and is supposed to be inhaled after having colonized in the mouth, probably in decayed teeth. Direct infection of the lung is very much questioned. The left lung is more often afifected than the right, and resembles a lung with fibroid phthisis, though the pearly gray or yellow nodules or granules (threadlike in appearance) are diagnostic, as is the contracted thorax, later on. The granule is a star-shaped body, composed of numerous threads with club-shaped ends which, together with the branch- ing segmented mycelium, is characteristic. The pus with which it is associated is epiphenomenal, and the disease may be confounded with abscess or phlegmon. Eighty-five to ninety per cent, of cases of involvement of the lung terminate fatally. However, the mortality is very much reduced if the superficial portion of the lung be involved, or if surgical principles are employed. The fungus of actinomyces is from one-half to two milli- meters in diameter, and the nodules which it forms soon begin to decay, but the process of growth keeps pace with that of decay. The disease spreads by the adjoining parts becoming infected, and sometimes metastasis occurs. It has been found in the crypts of the tonsils, lacrymal duct, and in carious teeth, from which places it is easy for the fungus to be aspirated into the lungs. When the lung is involved there is first pain, followed by 442 PARASITIC FUNGI 443 pleurisy and expectoration, pneumonia or bronchitis, or both. There is at this time great proHferation of round cells, which soon undergo fatty degeneration, and an abscess is formed which ruptures into the bronchia. The expectoration is of some aid in making a diagnosis, but although peculiar, it is not definite. Clinically, this disease can be diagnosticated by the presence of the yellow, seed-like bodies in the pus, which are visible to the naked eye, and, when rubbed between the fingers, have a greasy feel. The carnivorous animals appear to enjoy immunity from this disease. This, apparently bears out the theory that the dis- ease is due to a fungus or parasite growing on plants, which cattle may eat, thus becoming infected themselves, and in turn infecting those who may eat their flesh. Historical ( 1877-1903). — Ponfick was the first to recognize this disease in man. He had a case in which there was a meta- static growth in the right auricle, and numerous metastases in the lungs. (Die Actinomykose des Menchen, eine neue Infec- tionkrankeite auf bergleichend-pathologicher und experiment- eller Grundlage geschildert, Berlin, 1882.) The name of the parasite is Actinomyces bovis when found in cattle, but some writers term it actinomyces hominis when found in man. But whether found in man or in animals, it is evidently the same thing. The disease caused by this fungus is termed actinomycosis. Some writers do not seem to make a careful distinction between the name of the plant and the name of the disease; they use the terms as if they were synonymous. Belfield (1879) '^vas the first to discover this disease in America. Sebert, however (1848), was the first to publish anything on this subject, and, like others, did not know just what he had found. Bollinger (1877) found it in animals and was the first fully to describe the disease ; Dr. J. B. Mur- phy (1884) has the credit of being the first in the United States to discover it in man. 444 THE SURGERY OF THE LUNGS Israel published the results in thirty-eight cases. In seven- teen cases, the patient was infected in the mouth, or pharynx. In nine patients, the infection was in the air passages of the lungs. In seven, the infection was at some point of the ali- mentary canal, and in five, the point of infection was uncertain. Israel demonstrated that pure cultures could be made and that animals could be inoculated from them. He also proved that rabbits could be inoculated from man. (Klin. Beitrage zur kenntniss der Aktinomykose des Menschen, Berlin, 1885.) It is stated that the first case diagnosticated in man during life, was reported February 12th, 1889, by Powell and Goodlee to the Medico-Chirurgical Society. Richeralle (1892) re- ported five cases of simulating tuberculosis. {Miinch. Med. Woch., 1895, p. 49.) Partsch (1892) mentions a case of in- fection at the root of a bicuspid tooth. (Die eingang des Ak- tinomyces. Wien. Woch., 1897, p. 97.) Heuser (1895) re- ported a case of primary actinomycosis of the lung. Aschofif and Butler each reported a case which recovered. Karewski, Caglieri, Babrazes, and Visconti have also contributed to this subject. Treatment — Ruhraeh of Baltimore {Annals of Surg., vol. xxx) gave an analysis of sixty-five cases that had been re- ported as occurring in America. He says : " The thoracic cases do badly as a rule, no matter what treatment is followed." J. L. Sawyer {Jour. Am. Med. Assn., p. 13 14, vol. xxxvi, 1901) is one of the latest writers on this disease. He reports several cases, but only one case was of the lung. He recommends the administration of iodide of potassium, combined with hypoder- mic injections of a one per cent, solution of the same. The in- jections are to be given in one-half drachm doses, every third day. There will be a temporary increase in the symptoms, and swelling for about six hours after an injection. Dr. Sawyer found threadlike mycelia with clubbed ends in the urine, and also found traces of indican in nearly all cases. Five per cent, solutions of potassium permanganate, one per Plate LXXI Experiment on Lungs,, No. 14. page 489. PARASITIC FUNGI 445 cent, solutions of methyl violet, and five per cent, solutions of carbolic acid in doses of fifteen to forty-five minims, have all been used for parenchymatous injections. The head and neck are most frequently the seat of the dis- ease. Fifty-five per cent, of all cases have been found in these parts of the body, while twenty per cent, were in the thorax or lungs, twenty per cent, in the abdominal organs, and five per cent, in all other parts of the body. Garre reports ninety-six cases of the lung operated upon, with eighty-seven cases cured. BIBLIOGRAPHY Heuser, Berlin. Klin. Wochenschr., 1895, 1029-1031. AscHOFF, Berlin. Klin. Wochenschr., 1895, 738-765-786. Butler, Med. News, New York, 1898, LXXII, 513-515. Karewski, Berl. Klin. Wochenschr., 1898, 328-350-373. Caglieri, Am. Med. Assn. Jour., 1898, XXXI, 1173. Babrazes, Rev. de Med., Paris, 1899, XIX, 68-77. ViscoNTi, Primary actinomycosis puhnonare. Martin, Ztschr. f. Fleisch u. Milchhyg. Berlin, 1900, X, 152-153. Parascandolo, C., Clinical Med., Pisa, 1900, VI, 353-359- NossoLL, Centralhlatt fur die Gienzgebirte des Medizin und Chi- rurgie, June 25, 1902; p. 466. Garre, Journal American Medical Ass^n., 1902; XXXVIII, No. 12, March 22, pp. 798-9. ASPERGILLUS.— Virchow first mentioned it in 1856. It is a vegetable parasite, and has been described by Freyhau (IVieu. Med. Prcsse, 1882, p. 185). With the aspergilli, as with all other of the mould fungi which attack the human body, there is a tendency to lodge in some one of the internal organs. After lodgement, the mycelia grow out and form distinct foci. Three species of aspergilli are known to be pathogenic, i. e., Aspergillus fumigatus, Aspergillus niger, Aspergillus flavus or 446 THE SURGERY OF THE LUNGS flavescens. These species of fungi are widely distributed ; they are found at times on mouldy bread, etc. Persons should be very cautious of all mouldy foods. Some of the moulds are harmless, but all should be handled carefully. Birds are often observed with mycosis of the lungs caused by inhalation of the spores of the aspergilli. Other animals have also been found suffering from accidental infection. The most dangerous species is Aspergillus fumigatus. This mould is greenish in color. The conidia-bearers are short and hemispherical, very thickly set with sterigmata. The latter are, in shape, awl-like. The conidia are generally colorless, round and smooth, and show no membrane. This species is not known to have sclerotia. A temperature of thirty-seven to forty de- grees Centigrade is best for its growth. Aspergillus fiavus or flavescens ranks next to Aspergillus fumigatus in pathogenic power. This species is greenish- brown in color, with yellow or brown conidia, having a finely nodular surface. The sclerotia are very small and black. It grows best at about twenty-eight degrees Centigrade. Aspergillus niger is said not to be very malignant. It is brownish-black in color. The fruit-bearers are globular, and the sterigmata long and branching; the conidia, round and black, or nearly so, and the sclerotia, brownish-red and about the size of a rape-seed. The best temperature for its growth is about thirty-five degrees Centigrade. Among reports of pulmonary trouble, caused by these moulds, is that of Wheaton, who mentions a case in a child two and one-half years old. Bland Sutton (Trans. Path. Soc, 1885) gave a full account of these moulds in the air-passages of birds. Kidd (1886) showed by experiment that the injec- tion of the spores of aspergilli into the auricular veins of rab- bits produced them in abundance in various organs, especially in the kidneys. (Path. Soc. Trans.) Boyce (1892) remarks upon a case of aspergillus pneumonocoses (Jour. Bacter., Oct. 1892). He found them in small irregular cavities in the PARASITIC FUNGI 447 apex of the lung, forming white Ijodies aljout the size of a pin head, and resembhng calcified bodies. Furbruiger ( 1876) col- lected eleven cases (Beobach. iiber Lungenmycose beim Men- schen. Virchow's Arch., 1876, p. 330). There is no general infection ; and examination of the sputum reveals nothing. It is said to be always secondary. PNETTMONOMYCES.— For over half a century this fungus has been known as a causative factor in lung disease. The le- sions are similar to those produced by the other fungi. The symptoms and diagnosis are similar to those of aspergillus. It is this reason, perhaps, that has caused pneumonomyces to be mistaken for aspergillus. It is only by a microscopical exami- nation of the plant that positive knowledge of its identity can be obtained. Some writers consider pneumonomycosis to be caused by aspergilli, or have confounded the two. Von Dusch and Pag- enstecher call it Aspergillus Pulmonum Hominis. Stieda, Weichselbaum, and Rother also consider it to be an aspergillus, or care has not been taken to differentiate the two. Historical (1853-1903). — Bristowe (1853-1854) reported a vegetable fungus growing in the cavity of the lung. Cohn- heim (1865) reported two cases of fungoid growths in the lungs. Von Buhl (1878) reported on pneumonomycosis sar- cinica as a causative factor in diseases of the lung. Fuer- bringer (1876) reported cases of pulmonary disease in man caused by a fungus. Von Ziemssen (1876) published an arti- cle on pneumonomycosis. Manwerk (1881) reported cases of pneumonomycosis in the lung, and Roeckl (1884) also re- ported cases, (For symptoms, diagnosis, and treatment, see under these headings in the last chapter.) 448 THE SURGERY OF THE LUNGS BIBLIOGRAPHY 1. Bristowe, Trans. Path. Soc, London, 1853-54, V, 38-41. 2. CoHNHEiM, Arch. /. path. AnaL, etc., Berlin., XXXIII, 157-159. 2a. Stieda, Arch. f. path. Anat., Berlin., 1866, XXXVI, 279. 3. Von Buhl, Aerztl. Int.-Bl., Muenchen, 1876, XXIII, 324. 4. FuERBRiNGER, Arch. j. path. Anat., Berlin., 1876, LXVI, 330-65. 5. Von Ziemssen, Deutsches Arch. j. Klin. Med., Leipzig, 1876-77. XIX, 344-356- 5a. RoTHER, Char.-Ann., 1877, Berlin., 1879, IV, 272-77. 5b. Weichselbaum, Wien. Med. Wohnschr., 1878, XXVIII, 1289. 6. Manwerk, Cor.-BL, schweiz. Aerzte, Basel, 1881, XI, 225-32. 7. RoECKL, Amt. Ber. u. d. Versamml. deutsch Naturf. u. Aerzte. Freib., I, Br., 1884, LVI, 127-130. OIDIUM ALBICANS.— Oidium is frequently found in the bronchia, involving the mucous membrane, and occasionally in the tissues immediately underlying it. It is usually found in clusters, and more frequently in the medium-sized bronchia. It may be primary or secondary, and involve the parenchyma of the lung. It is primary, where there is a direct opening from the bron- chus into cysts or abscesses; secondary, when the fungus has first involved the oral or bronchial mucous membrane with the existence of a cyst, abscess, or laceration of the lung. It may also be secondary by the extension of the filaments into the lung parenchyma, when the fungus has developed upon the smaller bronchia. It may also develop upon lung tissue recently lac- erated from any cause, when the fungus is present anywhere in the respiratory tract. ( See chapter on Odium in heart. ) Plate LXXII. Experiment on Lungs, No. i6, page 490. CHAPTER XX ANIMAL PARASITES :— ECHINOCOCCUS, PARAGONIMUS WESTERMANI, CYSTICERCOSIS, TRICHINA SPIRALIS ECHINOCOCCUS. — Taenia echinococcus is the tape-worm in the dog, and its larvae enter the human body with food or water. The embryo passes through the wall of the stomach, or intestine, to develop in one or more of the abdominal, or thoracic organs; it is usually, retroperitoneal, when the peri- tonaeum is involved. It may, however, be within either the peritoneal or thoracic cavities. It is rarely found on the west- ern hemisphere, but is quite common in Iceland and Australia, especially among herders. Taenia echinococcus is the smallest of the tape-worms ; only the last segment is gravid with eggs. Man is not infected by eating meat containing the hydatid, because it is only the em- bryo of the taenia echinococcus which causes disease in man. If taken into the body in the mature state, the hydatid will be- come encysted without injury to its host. Here it forms its eggs, and is thus prepared to infect any animal into which it gains entrance. If the hydatid does not become encysted it is either digested, or passes out through the alimentary tract. Fifteen per cent, of all cases of echinococcus are of the lung, and are usually secondary when found there. Their entrance into a vein may cause instant death. Normal fluid in the cyst contains mineral salts in abundance, but no albumen. Occa- sionally the fluid contains sugar. The cyst may be destroyed by 449 450 THE SURGERY OF THE LUNGS calcification, or it may rupture into the pleura, or peritoneal cavity, into the alimentary, or bronchial tract, into the uterus, Fallopian tubes, bladder, kidneys, or ureters, or it may escape externally at any point through the thoracic or abdominal walls. The cyst is usually solitary, and is found at the base of the lung. It may, however, occupy the entire pleural cavity. The lung is usually invaded by an acephaloid cyst, which does not contain echinococci. Historical (1828-1903). — Todd (1852) reported a case of hydatid of the right lung, with recovery after expulsion of the hydatid. Bailey (1861) reported a case treated by incision of the sac after internal rupture. Hearne (1875) collected one hundred and forty-four cases. Of these, sixty-six recovered and eighty-two died. Forty-five of the sixty-two recoveries were cured by the bursting of the cyst into the air passages. Five were punctured, and twelve incised. McGillmary, quoted by Greenfield on case of Hydatid of the Lung {Clinical Society Transactions, 1877, Volume X, p. 103), reported sixty-five cases, of which nine were in the lung; he says that no portion of the lung seems especially prone to at- tack. Maydl reported four cases in which echinococci were found in the lung. Lehmann (1882) reported eight cases of cyst in the lungs with only one recovery, and that by operation. De Zouch's (1883) case of suppurating hydatid of the lung is one of the few reported in which any attempt was made at removal. Little was said concerning such a procedure for more than a century, not until Thomas (1885) suggested the treatment of cysts by the establishment of large openings into the sac, and subsequent free drainage. Thomas (1885) collected thirty-two cases of hydatid of the lung treated by incision, with twenty- five recoveries. He says there is a mortality of fifty-four per cent, if they are left alone; twenty-seven per cent, when punct- ure is employed, and one per cent, when resection and incision are resorted to. Plate LXXIII. Experiment on Lungs, No. i8, page 490. ANIMAL PARASITES 451 Lopez collected thirty-six cases treated by incision of cyst, with thirty cures. Madeliing reported nineteen cases of hy- datid of the lung, in which there was no operation. Ten re- covered, three were relieved by opening into the bronchus, and six died. Richeralle (1888) reported a case and Lorieux furnished contributions (1889) to the study of hydatid cysts. Thomas ( 1889) reported another case, that of a large echinococcus cyst of the left lung, spontaneously rupturing into the bronchus, and thus causing sudden death. Nicholson (1890) reported a case of primary hydatid of the left lung, and Danlos gave notes on a similar case. Ferraud (1890) reported a case of hydatid cyst, opening spontaneously into the bronchus. Mackenzie (1890-91) re- ported a case, which he treated by paracentesis. He reported later a case of hydatid of the lung, which proved fatal, by rupt- uring into the bronchus nine hours after treatment by aspira- tion. (Transactions Clinical Society, London, 1891-92, XXV, 215-220). Ord and Robinson (1891) incised the right lung in a case of a suppurating hydatid cyst, and drained, but the patient died. Marconnet published observations on hydatid cysts in the lungs. RevilHod (1891) published a paper on echinococcus infiltration of the superior lobe of the right lung. Pardy (1891) had a case of hydatid of the lung bursting into the pleura. Thoracotomy was employed, a piece of rib removed, and the patient recovered. Miers reported a case of hydatid cyst of the right lung rupturing into the bronchus. Bristowe (1891) treated a case of living hydatid of the lung by aspiration, followed immediately by subcutaneous em- physema; death resulted from suffocation, due to the rush of hydatid fluid into the bronchus. Maydl (1891) collected six- teen cases treated by puncture. Of these eleven died, five from suppurating- pleurisy, six from puncture alone, making a total 452 THE SURGERY OF THE LUNCzS mortality of sixty-nine per cent. The hydatid may extend from the pleura into the lung. Laveran (1892) reported a case; Clyhorn and Mackenzie, each treated a case of hydatid of the lung by paracentesis; Nuvoli (1892) treated a case of lung hydatid surgically; Bouilly (1892) employed pneumonotomy in a case of hydatid of the lung, as did Netter (1892-93). Miralle and Scott (1893) also reported cases. Trzebicki reported forty-five operations. There were thirty- seven complete cures ; one fistula resulted ; then six deaths, and in one case, the result was not known. Sophianopoulos and De Villeneue (1894) published reports of cases. Todd (1894) operated upon a case of hydatid of the lung, and Chepple, Tatu- sescu, Thomas, and Troquart (1895), each reported cases. Cooke (1895) published short notes on two cases of suppurat- ing hydatid of the lung, simulating phthisis, which were cured by operation. Tuffier (1896) also employed pneumonotomy in a case of hydatid of the lung, and Vespa, Eberson, and Clerc ( 1897) increased the literature of the subject by their published reports. Geraud (1897) published his paper on diagnosis of hydatid of the lung, and Reed ( 1897) is another Australian to whom we are indebted for reports on this subject. In Milan there appeared (1897) a report on a case of pa- renchymatous suppurative echinococcus cyst, and Nicodemi, an Italian, reported cases, followed by Potherat (1897), of Paris. Sterner (1898) published his operative methods in treating echinococci of the lungs. Bacelli and Penrose ( 1897) reported cases of hydatid cysts. From Australia, which has given so much to the literature on this subject, came Wood's report of three cases. His fellow-countryman, Hinder, re- ported a fatal case of hydatid of the lung. Beck. Pitzorno, Reid, Nicodemi, Lipari, and Piazza-Martini (1898), made contributions to the literature of hydatids of the lungs. Davies treated a hydatid cyst of the left lung by resection of a rib, and incision of the cyst wall. Plate LXXIV. Experiment on Lungs, No. 19. page 490. ANIMAL PARASITES 453 Symptoms. — Often there is no pain, only a bulging of the chest wall. It may be confounded with solid tumor of the liver, but it must be remembered that a cyst in the liver may burst through the diaphragm into the pleural cavity. In such a case there is severe pain and urgent dyspnoea. Death may result from shock, or pleuritic inflammation. Such a state of affairs is shown by sudden expectoration of fluid, generally purulent or bloody in character, containing echinococcus vesicles, entire or in fragments, and usually followed by a pneumothorax. Diagnosis. — Bulging of the chest wall, and circumscribed dulness are characteristic. The respiratory sounds are absent. There is no biliary coloring when the lung alone is involved, but this occurs if the liver is also involved. The diagnosis is doubtful until the cyst ruptures ; then the microscope is the only sure means of diagnosis. If the instrument reveals shreds of membrane, scolices, or booklets, in the fluid the diagnosis is certain. Fluid withdrawn by aspiration will contain booklets, etc., but at times it is necessary to supplement the work of the microscope by chemical analysis. There are cases in which all means of diagnosis result in failure. The most eminent authorities agree that only forty per cent, of all cases are diagnosticated during life. Devine says that two-thirds of lung cases die when left to themselves. The growth is very slow, ten to fifteen years being the average duration. As it is not malignant, and seldom painful, patients do not seek aid ; for this reason there are, doubtless, many more cases than the published statistics would lead us to suppose. Treatment — Those who have had the most experience in treating this disease claim that it is not amenable to internal medication. Some writers state that nitrate of silver, ferric sulphide, iodine, carbolic acid, or bichloride of mercury taken internally, or injected into the cavity have been beneficial. Also, that small doses of arsenic will prevent the eruption of potas- sium iodide, which is much used in treating this disease. Tuberculin, injected as in tuberculosis, has also been beneficial. 454 THE SURGERY OF THE LUNGS The majority of writers agree that surgery offers the surest and safest mode of treatment. When it has been deemed best to resort to surgery, divide the ribs posteriorly, and Hgate the bleeding points. The cav- ity once located, the finger may then be introduced through the lung into the cyst wall. The mother cyst is to be grasped with the forceps and delivered. If ruptured in this attempt, irrigation, which should always be resorted to, will probably de- liver the daughter cysts. The subsequent treatment should be as for an open chest wound. " Prevention is better than cure," applies with special force to this disease. The experience of Iceland is that it is neces- sary to exclude dogs from those localities in which their faeces may contaminate the food or drink, not only of man, but even of sheep and cattle; for it is probable that cattle are infected chiefly by the deposit in their pastures of the faeces of infected dogs, or by their drinking water thus contaminated. Neither should dogs be allowed to eat the refuse of viscera of dead or slaughtered animals, or in fact, any uncooked flesh. BIBLIOGRAPHY ToDD, Medical Times and Gazette, London, 1852, n. s., IV, 1-3. LoRiEUX, Bordeaux, 1889, No. 36. Thomas, Aiistralas. Medical Gazette, Sydney, 1889-90, IX, 73. Nicholson, Lancet, London, 1890, I, 747. Ferraud, Bull. Societe Med. de VAnnee 1890, Auxerre, 1891, XXXI, 65-69. Mackenzie, St. Thomas Hospital Rep., 1890-91; London, 1892, No. XX, 336. Mackenzie, Transactions Clinical Society, London, 1891-92, XXV, 215-220. Ord and Robinson, Transactions Clinical Society, London, 1891-92, XXV, 125-128. Marconnet, Prog. Medical, Paris, 1891, 2 s., XIII, 517-520. ANIMAL PARASITES 45 5 Revilliod, Rev. Med. de la Suisse Rom., Geneve, 1891, XI, 129- 133- Pardy, Australia Medical Journal, Melbourne, 1891; n. s., XIII, 379-381- MiERS, Medical Gazette, Sydney, 1891-92, XI, 409. Bristowe, Transactions Clinical Society, London, 1891, XXIV, 73-78. Laveran, Medecine Mod., Paris, 1892, III, 57-59. Clyhorn, New Zealand Medical Journal, Dunedin, 1892, V, 169. Mackenzie, Lancet, London, 1892, I, 871. NuvoLi, Gazz. di Roma, 1892, XVII, 241-246. BouiLLY, Bull, et Mem. Societe de Chirurgie, Paris, 1892, n. s., XVIII, 589. Netter, Bull, et Mem. Soc. de Med. d. Hop., Paris, 1892, 3 s., IX, 613-622. Netter, Bull, et Mem. Soc. de Chirurgie, Paris, 1893, n. s., XIX, 389-394. MiRALLE, Gaz. d. Hop., Paris, 1893, LXVI, 105-113. Scott, Australas. Med. Gaz., Sydney, 1893, XII, 142-144. SoPHiANOPOULOS, Galeno, Athens, 1894, Kd., 315-319. De Villeneue, Atti d. Assn. Med. Lomb., Milano, 1894, 105-110. Todd, Intercol. Quar. Jour. Med. and Surg., Melbourne, 1894, I, 259-261. Chepple, New Zealand Medical Journal, Dunedin, 1895, VIII, 179-184. Tatusescu, Spitalul bucuresci, 1895, -^V, 44-46. Thomas, Revue Medicale de la Suisse Rom., Geneve, 1895, XV, 337-340. Torquart, Journal de Med., Bordeaux, 1895, XXV, 549-561. TuFFiER, Association Franc, de Chirurgie, Paris, 1896, X, 389- 391- Vespa, Bull, di Soc. Lancissiana d* Osp. di Roma, 1894, 1895, XIV, p. 26. Eberson, Niederl. Tidjdschar. v. Geneesk., Amsterdam, 1897, 2 r., XXXIII, d. i., 331-345. Clerc, Bull. Societe Anat., Paris, 1897, LXXII, 541-543. 456 THE SURGERY OF THE LUNGS Geraud, Bull. Med., Paris, 1897, XI, 845. Reed, Intercol. Med. Journal, Melbourne, 1897, II, 608-611. Gazette d'Osp., Milano, 1897, XVIII, 1423. NicoDEMi, Gazette d'Osp., Milano, 1897, XVIII, 556-568. Protherat, Rev. de Chirurgie, Paris, 1897, XVII, 1028. Sterner, Centrbl. }. Chirurgie, 1898, XXV, 23. PoTHERAT, Association Franc, de Chirurgie, Paris, 1897, XI, 363- 366. Bacelli, Suppl. d. Policlin., Roma, 1897-98, IV, 1 205-1 207. Penrose, Lancet, London, 1898, II, 992. Wood, Intercol. Med. Journal, Melbourne, 1898, III, 475-482. Hinder, Australas. Med. Gaz., Sydney, 1898, XVII, 348. Beck, Journal American Medical Association, 1898, XXX, i, 1238. PiTZORNO, Gaz. d'Osp., Milano, 1898, III, 522. Reid, Intercol. Med. Journal, Melbourne, 1898, III, 522. Nicordeni, Practice Firenze, 1897-98, III, 71, 104, 129. LiPARi, Gaz. d' Osp., Milano, 1898, XIX, 1573. Piazza-Martini, Con., XIII, Observations, Palermo, 1898, p. 74. FRAN9AIS, H., Bull, et Mem. Soc. Anat., Paris, 1900, II, 384. Sainton, P., Rev. de Therap. Med.-Chir., Paris, 1900, LXVII, 475-478. Palleri, G., Gazz. Med. de Marche, 1900, VIII, No. 51. Halipre, Echo Med., Toulouse, 1900, XIV,. 126-130. Halipre, Normandie Med-, Rouen, 1900, XVI, 62. Parascandolo, Clin. Med., Pisa, 1900, VI, 185-187, 193-197. Zambra, Semana Med., Buenos Aires, 1900, VII, 458-461. Schreckhaase, Inaug-Diss., Griefswald, 1900, Juli. Sainton, P., Rev. de Therap. Med.-Chir., Paris, 1900, LXVII, 475-478. Crouchet et Fauquet, Jour, de Med. de Bordeaux, 1900, XXX, III. Loi, C, Riforma Med., Palermo, 1900, III, 305. Caeser, J., Lancet, London, 1900, II, 1872-73. JosiAS, A., Bull, et Mem. d'Hop., Paris, 1901, XVIII, 436-441. Foucher, a. L., Lille, 1901, 68 p. Cassuto, E., Bull. Hop. civ. Franc de Tunis, 1902, X, 117-123. Plate LXXV. Experiment on Lungs, No. 20. page 491. ANIMAL PARASITES 457 GiARRE, C, Un caso di cisti voluminosa da echinococco del pol- mone deatro in bambina di 7 anni curato coUa estirpazione. Riv. crit. di Clin. Med., Firenze, 1902, III, 6. PAKAGONIMTJS WESTERMANI — This distoma is a trema- tode, indigenous to Asia, found in China and Corea, and espe- cially prevalent in Formosa and Japan, where it has never, however, been found in the hog. It is found in both man and domesticated animals, such as the dog, cat, and hog, in the United States, Paragonimus Westermani usually attacks the lungs by the formation of nodules, generally near their roots. As a rule, the nodules are occupied by two, probably male and female, parasites. The brain has been found infested by them, in which case the cortical substance is involved, causing epilepsy. Man- son, who first described this disease, terms it parasitic haemop- tysis. It is very common in Japan ; we owe most of our knowl- edge of it to the Japanese physicians. Baelz said that in one village in Japan nearly all the inhabitants harbored lung worms. Historical. — Kerbert (1878) described a distoma that had been found in a Royal Bengal tiger. This is one of the earliest published reports. Ward(i894)of the University of Michigan, reported that a parasite discovered by Professor Kellicott, of the University of Ohio, was identical with that of Kerbert. The United States Bureau of Animal Industry reported fifty cases in the dog, found in Ohio. The sixteenth report gives a number of instances in which it was found in the hog. This same report contains a resume of the literature on the subject, and it has been largely drawn upon for the following matter. In Japan and Formosa from fifteen to twenty-five per cent, of the inhabitants suffer from haemoptysis caused by this para- site. It is often confounded with tuberculosis, since it can only be diagnosticated by aid of the microscope. It is not found in the very young or in the very old. Some of the au- 458 THE SURGERY OF THE LUNGS thorities state that persons of strong constitutions are more sub- ject to this disease than others. It has been found in persons following various pursuits and occupying various stations in life. In fifty-nine cases the ages were known; of these, forty- five were between eleven and thirty. Of sixty-six cases of known sex, fifty-eight were males, and eight females. This parasite has been found in the same domesticated animals in this country as in Japan. It is also now found in man in this country, having been brought here by soldiers returning from Asia. Father Clos, S.J., who has recently returned from the Phil- ippines, says that he has observed numerous cases of haemoptysis among the natives. It should" be remembered that infection of the lung may be complicated by infection of the brain, liver, or other organs. Symptoms, Diagnosis, and Treatment. — The sputa are similar to those of pneumonia, of a dirty brown or red color, due to the microscopic worm eggs. Spitting of blood is common ; in- termittent cough is common but not constant. The only con- stant factor is the presence of the eggs in the sputum. As much as ten or twelve ounces may be expectorated daily, containing thousands of eggs. Usually the disease makes slow progress, and at the end of several years, six, eight, or ten, the patient is no worse. This form of haemoptysis is seldom associated with other serious lung troubles. Physical examination reveals nothing abnormal, except in the worst cases. The temperature is normal, or only slightly elevated. Frequently there is slight oedema. Patients de- scribe a sensation in the chest of oppression, or of heat, or mere irritation. Occasionally, there are neuralgic pains in the chest. The sufTerer may get out of bed, and months pass before a re- lapse occurs. But the relapse will come sooner or later. This happens over and over again, until the patient is worn out. No benefit has been derived from medicine in treating this disease. General treatment is, undoubtedly, useful ; but rest Plate LXXVI. Experiment on Lungs, Xo. 21, page 491. ANIMAL PARASITES 459 and good food are essential. Exertion aggravates all the bad symptoms. Yarnagiwa thinks surgery might be tried if the exact loca- tion of the more superficial cysts could be learned. BIBLIOGRAPHY CoBBOLD, T. S., Trans. Linn. See. London, XXII (1856-59), pp. 363-366, Tab. LXIII. Baelz, Lancet, London, 1880, II, pp. 548-49. Baelz, Uber parasitare Hamoptoe. Central, f. d. med. Wiss., XVIII (39), 25 Sept., pp. 721-722. Kerbert, Zool. Anz., I, pp. 271-273. Manson, Med. Times and Gaz., London, July 8, 1882. Yamagiwa, K., Arch. f. Path. Anal. u. Phy. u. f. Klin. Med., CXIX (2), 447-460. Ibid., ditto, CXXVII, 3 Hft., 446-456. Railliet, Le Naturaliste, XII, 142-143. Yamagiwa and Inouye, Zeit. Med. Geo. Tokyo, IV, 21 Hft. (Art. No. 7), 1890. Weber, Tijdsch. der Nederl. Dierk. Vereen., 2 s.. Ill, 2 versl. pp. LXXXIII-LXXXIV. Blanchard, R., Note sur quelques vers parasites de I'homme. Compt. Rend. Soc. Biol., Paris, 9 s.. Ill, pp. 604-615, 1891. Braun, Max, Vermes (Bronn's Klassen und Ordnungen desThier Reichs, Bd. IV, 1892, Lief. 18-27, PP- 561-816). Stiles, Bull. Johns Hopkins Hosp., V, 57-58. Ward, Vet. Mag., II, pp. 87-89. Ibid., Med. News, Philadelphia, LXVI, pp. 236-239. Blanchard, R., Traite de Pathologie Generale (Bouchard), II pp. 649-932. Jaksch, R. von, and Cagney, Jas., Clinical Diagnosis, London, 1897. Simon, Manual of Clinical Diagnosis, 2nd ed., Philadelphia and New York, 1897. Looss, A., Zool. Jarh. Abt. }. Syst., Gcorg. u. Biolog. d. Th., XIL pp. 521-784, 1899. 460 THE SURGERY OF THE LUNGS Braun, Max, Uber Clinostomun Leidy. Zool. Anz., XXII (602) November 27th, pp. 484-488, 1899. Stiles and Hassal, Sixteenth Annual Report, Bureau of Animal Industr)', U. S. Dept. Agr., Washington, D. C, 1900. PTTLMONAP-Y CYSTICERCOSIS — Cysticercosis is a para- sitic disease caused by the presence of entozoons. These ento- zoons, known as cysticerci, are the larvae of various species of taeniae (tapeworms). Before their identity as embryonic forms of tapeworms was discovered, the cysticerci were con- sidered to be a distinct genus of the order Cestoda. Hence, the many names which have been given to them. The cysticerci are the spherical or oval embryos from which the head (scolex) of the tapeworm develops. It is not the most primitive form of the tapeworm, as it is developed from another embryonic form. Many of the animals which are found about the habitations of men harbor the various embryos of the tapeworm. Thus the embryos gain entrance into a human host to develop into the mature strobila, or fully developed tapeworm. The cysticerci are found in all the domesticated animals whose flesh is used for food. The use of uncooked meat ; soiling of the hand by working, or handling dirt, etc., in which the faeces of these ani- mals, or of fowls may have been deposited, are fruitful sources of infection. So, too, persons who harbor tapeworms, or from whom a tapeworm may have been expelled, become self-infected through the hands coming in contact with the anus in sleep, from eggs which may escape per anum and stick to the under- garments, etc. The cysticerci have been known to invade all parts and organs of the human body. Cysticercosis of the lungs, how- ever, is comparatively rare, but by no means unknown, as wit- ness the reports of cases (see bibliography). It is quite probable that some of the cases diagnosticated and reported as hydatid cysts of the lungs, have been, in reality, cases of pul- monary cysticercosis. A mistake of this character could be ANIMAL PARASITES 46l made easily, since the dog tapeworm (taenia echinococcus) is the smallest tapeworm known, and greatly resembles certain kinds of cysticerci. Measly pork or beef is caused by cattle and hogs being in- fected with cysticerci, which have become encysted. The cysts can be seen with the naked eye in salt pork or corned beef when dry; but they become invisible when the meat is damp. In meat, these cysts appear as small, white, calcareous spots, about the size of a pin-head. While in man, the cysts range in size from that of a pin-head to that of an adult head. The lungs may become infected by carrying soiled hands to the mouth ; by cysts of infected meat being broken in the mouth and the cysticerci, thus set free, penetrating the oesophagus; and by the migration of cysticerci from other organs or parts of the body. The author found cysticerci in the sputum and urine of a woman fifty-five years of age, under the care of Dr. W. E. Langdon. She resided on a farm and cared for several kind of fowl. Symptoms, Diagnosis, and Treatment. — The cysts, themselves, rarely give any trouble, but the increase in size may produce grave complications, mechanically. If the cysticerci are free, or if they escape from the cyst, many grave complications will result. The symptoms of pulmonary cysticercosis present nearly the same clinical picture as hydatid cysts of the lungs. In addition there are frequent asthmatic attacks, emaciation, loss of appe- tite, etc. A microscopical examination afifords the only means of making a positive diagnosis. At times the microscopical ex- amination may need to be supplemented by a chemical analysis, but, generally, a microscopical examination is sufficient ; eggs, encysted embryo, heads, etc., being found in the fluid. The microscope should be used as a regular routine procedure in all clinical examinations. Very often a chemical analysis fails to reveal the most important thing. 462 THE SURGERY OF THE LUNGS A bottle of urine, and also of sputum, were left at one time for examination. As is the usual practice in the office, the urine was first placed undc. the microscope. At first, there were only- evidences of diabetes, and intravesicular inflammation. A chemical analysis would have confirmed this diagnosis, but a little further search discovered the true cause of the disease and explained all the clinical symptoms. For, there, in plain view, were two cysticerci. Here were evidences, which vitiated the inductions previously made. It is claimed that no medicine will do any good in certain forms of cysticercosis. But in case of pulmonary cysticercosis some hold that arsenic, iodides, etc., may be effective. All, however, agree that when the cysticerci are accessible, the sur- geon's knife furnishes the most reliable means of treatment. BIBLIOGRAPHY Ramesay, " EXfilvdXoyia or, Some Physical Considerations of the Matter, Origination, and Several Species of Worms, Macera- ting and Direfully Cruciating Every Part of the Bodies of Mankind, of all Ages and Constitutions; whereby it doth probably appear to be an Epidemical Disease, killing more than either the Sword or Plague. Together with their Various Causes, Signs, Diagnostics, Prognostics, the Horrid Symptoms by them Introduced, as also the Indications and Methods of Cure. All of which is Medicinally, Philosophically, Astro- logically, and Historically Handled," London, 1668. Lewald, De cysticercarum in taeniis metamorphosi pascendi expcrimcntis in Institute physiologico, Vratislar. Berlini, 1852. LANKESTER-KtJCHENMEiSTER, On animal and vegetable parasites of the human body. London, 1857. Passot, Note sur le t^nia, et sur I'cxpulsion par I'dmetiquc, d'un de ces parasites dans un cas dc pneumonic. Gaz. med. de Lyon, i860, XII, 131-134. Plate LXXVII. Experiment on Lungs, No. 22. page 491. ANIMAL PARASITES 463 Carter, On a Bisexual Ncmatoid Worm which Infests the Com- mon Housefly (Musca domcstica) in Bombay. Trans. Med. and Phy. Soc, Bombay (1860-61), n. s., VI, app, pp. Ixii- Ixvi. RoELKER, On Taenia and Cysticercus. Cin. Lancet and Obser., 1863, VI, 329-339. Smith, Human entozoa, London, 1863. Oldham, On a Cystic Parasite Infecting Sheep. Indian Med. Gaz., Calcutta, 1873, VIII, 204. CoBBOLD, The Internal Parasites of our Domesticated Animals. London, 1873. Lesbini, Des larves parasites trouves chez I'homme. Acta Acad. nac de cien. exact., Buenos Aires, 1878, III, 41-63. Hayem, Lesion parasitaire simulant les tubercules, etc. Bull. Soc. Anat. de Paris, 1875, L, 756. Laboulbene, Sur les tenias, les ecchinocoques, et les botrio- cephales de I'homme. Bull, et mem. d'hop. de Paris (1876), 1877, 2 s., XIII, 38-82. Rochefortaine, Pentastome denticule provenant du poumon. Compt. Rend. Soc. deBiol. de Paris, 1876, Paris, 1877, ^ s., Ill, 261. Leuckart (Trans, by Hoyle), The Parasites of Man. Edinburgh, 1886. Rougier-Grangeneuve, Maladies vermineuses et maladies in- fectes. Bordeaux, 1880. PiANA, Di un nuova specie di tenia . . . e di un nuova cisti- cerco. Mem. Accad. d. c. d. Inst, di Bologna, 1880. Gibbes, Nematode worms in the lungs, etc. Trans. Path. Soc, London, 1883. MoNiEZ, Sur les cysticerques des tenias. Rev. Internal, de sc. bioL, Paris, 1880, V, 135-152. Remmert, Cysticercus cellulosae. Berlin, 1893. Kuss, Diagnostico de la cisticercosis en la especie humana. Arch. de la Policlin, Habana, 1897, V, 51-58. Ricketts, B. M., and Langdon, W. E., Cysticercus in the Lung and Urinary Bladder. N 464 THE SURGERY OF THE LUNGS TRICHINA SPIRALIS.— Trichina Spiralis is a nematode worm found principally in the pig, but occasionally in man after the ingestion of pig meat. The parasite perforates the intestinal wall, and enters the various muscular tissues there- after. It becomes encapsulated chiefly in the diaphragm, mus- cles of the back, shoulder, neck, eye, larynx, tongue, and oc- casionally the muscles of the lung. The cyst is ovoid in shape, at first transparent, becoming opaque and ultimately calcifying. It is coiled, and the female is larger and more numerous than the male. Treatment. — The same surgical measures are applicable to all lesions produced by parasites, whether fungdid, animal or bacilli. A positive diagnosis, even with the microscope, cannot always be made. Trichinae are said to be especially difficult to detect. The most important features in all are the complete removal and evacuation of the cyst, with annihilation of its occupant. In all cases the resection of one or more ribs is necessary, together with fixation, if possible, of the cyst wall to the thoracic wall, at a point corresponding to the greatest prominence of the cyst. This is to be done whether it occupies the anterior or posterior surface of the lung, or its base or apex. If the mediastinal wall should be involved, the sternum should be sufficiently removed to permit of free drainage through the mediastinal space. The cavity, in either event, should be thoroughly irrigated with sterilized water ; great care being exercised to see that all debris is removed. When this is done, the inner wall of the cavity should be brushed with a saturated solution of carbolic acid, iodine or formaldehyde ; and the cavity packed with gauze, the end of which should be se- cured externally. The amount to be used must be governed by the necessity of controlling bleeding. The frequency of chang- ing the packing, and the amount to be used should be governed also by necessity. If the cyst wall cannot be fixed to the chest wall, one should not hesitate to incise it freely and expose it through the pleural ANIMAL PARASITES 465 cavity ; care being taken to have perfect drainage at the lowest point in the cavity. If the bronchus has been opened by rupt- ure of the cyst, firm packing of the cyst cavity will be the more essential, as such a rupture in connection with an external open- ing, might cause partial or complete apneumatosis of one or all of the lobes of the lung involved. BIBLIOGRAPHY Hennen, Principles of Military Surgery, 1829, p. 372. Larrey, Clinique Chirurigicae, 1832, II, 195. Hastings and Storks, Medical Times and Gazette, December, 1844. Norman, Prov. Med. Journal, 1844. Jones and Sieveking, Manual of Pathological Anatomy, ist American Ed., Philadelphia, 1854. Velpeau, a. a. L. M., "Operative Surgery," 3 Volumes, New York, 1856. McDonnell, Dublin Quar. Journal, 1864, XXXVIII, p. 205. Flint, Austin, Principles and Practice of Medicine, 3d Edition, Philadelphia, 1868. Fraentzel, Krankheiten d. Pleura. Ziemssen's Handbuch, 1875. Erichsen, John Eric, Science and Art of Surgery from 7th Eng- lish Edition, Philadelphia, 1878. HiRD, Medical Times and Gazette, 1878, II, p. 514. Montar-Martin, Etude sur les Pleuresies Hemorrhagiques, Neo- membrane, etc., Paris, 1878, p. 162. Woodward, J. J., Medical and Surgical History of the War of the Rebellion, ist Issue, Washington, 1879. Gross, Sam. D., System of Surgery, 6th Edition, 2 Volumes, Philadelphia, 1882. Holmes, T., System of Surgery, ist American Edition from 2d Enghsh Edition, Philadelphia, 1882. CuRNOW AND KiDD, Path. Soc. Trans., 1883, 1885. Roberts, Fred. T., Theory and Practice of Medicine, Fifth Amer- ican Edition, Philadelphia, 1884. 466 THE SURGERY OF THE LUNGS Walsham, Medical Times and Gazette, 1884, I, p. 452. Penzoldt, Verhandl. des Congr. }. Inn. Med., 1885-86, p, 58. Hamilton, F. H., Principles and Practice of Surgery, New York, 3d Edition, 1886. Gray, Henry, Anatomy, New American Edition from nth Eng- lish, Philadelphia, 1887. Wyeth, John A., Text Book on Surgery, New York, 1887. Wheelhouse, British Medical Journal, 1887, II, 1141. Neisser, Die Echino-Kokkenkrankheit, Berlin, 1887. Jacobson, W. H. a.. Operations of Surgery, Philadelphia, 1889. Agnew, D. Hays, Principles and Practice of Surgery, 2d Edition, Philadelphia, 1889. Senn, Nic, Principles of Surgery, Philadelphia, 1890. James, Trans. Med. Chir. Soc, Edinburgh, 1890-91. KoLiSKO, Wien. KHn. Wochenschr., 1891, p. 665. Heydenreich, Semaine Med., 1891. Treves, Fred, Operative Surgery, Philadelphia, 1892. Delafield and Prudden, Pathological Anatomy and Histology. New York, 4th Edition, 1892. Keen and White, American Text-Book of Surgery, Philadelphia, 1892. Harris, Intrathoracic Growths, St. Barth. Hasp. Reports, 1892, Vol. XXVIII, p. 73. BoYCE, Journal Path. Bad., October, 1892. Schlange, Zur Prognose der Aktinomycose, Deutsch. Ges. }. Chir., 1892. Pitt, Lectures on the Surgery of the Air-passages and Thorax in Children. Lancet, October, 1893. Bramann, Verhandl. d. Deutsch. Ges. f. Chir., 1893, p. 114. Hale and Goodhart, Clinical Society's Transactions, 1893. Jaffe, Transactions Path. Society, London, 1894. Senn, Nic, Pathology and Surgical Treatment of Tumors. Phila- delphia, 1895. Warren, John Collins, Surgical Pathology, Philadelphia, 1895. Dennis, Fred. S., System of Surgery, Philadelphia, 1895. Semaine Medicale, February 6, 1895. Plate LXXVIII. Experiment on Lungs, No. 24, page 491. ANIMAL PARASITES * 467 RiEDiNGER, Congress Franf. de Chir., 1895, p. 99. LoCKWOOD, Traumatic Infection, 1895, P- 23. Moore, Dublin Quar. Journal, XXXIX, 279. Beez, liber Seltenere Vorkommnisse bei Necrose und Vereiterung von Bronchial-druesen. Jena, 1895. PoLAiLLON, Affections Chirurgicales du Tronc. Paris, 1896. West, Clinical Society Reports, April, 1896. Murray, Extensive Resection of Ribs for Emphysema. Annals of Surgery, May, 1896. Marie, Lemons de Clinique Medicale, Paris, 1896. Tillmanns, Dr. Her., The Principles of Surgery and Surgical Pathology. 'New York, 1897. Paget, Stephen, Surgery of the Chest. New York, 1897. Wharton and Curtis, Practice of Surgery. Philadelphia, 1898. Sajous, C. E. de M., Annual and Analytical Cyclopaedia of Prac- tical Medicine. Philadelphia, 1 898-1 900. Surgeon-General United States of America. Reports for 1899 and 1900. Deaver, 'John B., Surgical Anatomy. Three Volumes, Phila- delphia, 1900. Stimson and Keyes, Jr., Wounds and Injuries of the Chest. Sajous's Annual and Analytical Cyclopaedia of Practical Medicine. Vol. VI, 1901. RuMPF, Uber Newbildungen im Mediastinum. Freiburg. PLATES, PART II. Repair of Lung. Sutures. Dog's Lungs, in situ (Anterior view). Dog's Lungs, in situ (Posterior view). Sections of Dog's Lungs (7). Photos of dogs' lungs after operation (22). 468 EXPERIMENTAL RESEARCH ON THE LUNGS OF THE DOG. This series of experiments was conducted at the labora- tories of the University of Cincinnati from June 25 to Sept. i, 1900, for the purpose of demonstrating how far surgical inter- ference with the lung could be carried, and also to establish the best technics in lung surgery. Although the anatomy of the lung has been rather exten- sively treated, the physiology and pathology have been only considered as they bear directly upon the surgery. The author takes this opportunity to thank Drs. J. Stuart Wallingford, T. G. Sellew, and his student, C. T. Souther, for their most valuable and devoted services. Fifty dogs were used in conducting these experiments. No abnormalities, or parasites were found in any of the dogs. Neither were any malignant or benign growths found. Only one dog had hernia, and that was ventral. No case of host- operative hernia developed. One hundred and sixty-five dogs were used for all purposes, and none of the above conditions was found. Only one dog had tuberculosis (No. 48). After No. 5, each dog was thoroughly scrubbed, the chest shaven, and skin washed with turpentine. Ether was invari- ably employed, except for producing death, for which purpose chloroform was used. No antiseptics were used, except tur- pentine, which was applied to all wounds, after the incision had been closed with silkworm gut. Dressings of any character were discarded after dog No. 5, the wounds being left unpro- 469 470 THE SURGERY OF THE LUNGS tected. Drainage was employed in only one case, No. i8, which died on the fifth day, from infection. The food consisted of water, bread and milk, and raw beef. The ages and weights given are only approximate. In no case did an abscess of the lung follow any of these operations. CHAPTER XXI THE LUNG OF THE DOG EXPERIMENTAL RESEARCH An anterior view of the thoracic organs of a dog shows how nature provides protection for the more deHcate and vital or- gans. The heart will be seen surrounded, and overlapped in part, by the lobes of the lungs. The right upper lobe of the lung overlaps the entire upper portion of the heart, while the left upper lobe affords like protection to the other side. The middle lobes too, close in around the heart, forming a natural, living, air cushion, thus warding off injuries to the heart. The right lower lobe is the largest lobe of a dog's lung, while the right middle lobe might be taken for a process of the former. The shape of the butterfly lobe shows why it received its name. The left upper lobe overlaps the right upper lobe for a short distance, and thus aids in completing the air cushion-like pro- tection of the heart. The left middle lobe overlaps both the upper and lower lobes, and fills in the space between the two ; the left lobe extends downward more than the others. A posterior view of a dog's thoracic organs, in situ, is also interesting. The arrangement and connection of the various lobes may be very clearly comprehended. The thoracic aorta is perfectly visible, as are the intercostal branches, which are seen shooting off in pairs at regular intervals. Viewed from this aspect, the bronchial gland can be seen. When all the bronchial, pul- 471 472 THE SURGERY OF THE LUNGS monary, and arterial vessels are injected with a solution of starch, aniline, and formalin, the thoracic organs will assume and retain their natural shape and appearance, after removal. It will be found that some of the injected material will escape, but sufficient material will remain to keep the organs distended. Now, if the lungs be viewed from a posterior aspect, the thoracic aorta, the great pulmonary veins, the bronchus, in situ, in the lung tissue, etc., can be seen easily. Such an ex- amination will give one not only a better knowledge of the dog's lung, but of the human lung as well. The plates numbered I and LVII to LXIII show the normal appearance of the dogs' lungs, while plates num- bered LXIV to LXXXVII show the appearance of the dogs' lungs, after the various operations described thereunder. These experiments proved that, in case of a dog, the middle of the right upper lobe may be severed by throwing a kangaroo tendon around its middle, and occluding the bronchial lumen; the inferior lobe of the right lung may be split, and, if sutured at once, recovery will ensue. A dog will recover, even after a piece has been torn from a lobe. An incision may be sutured with perfect confidence. An entire lobe may be removed, at least in case of traumatic injury. In one case, the inferior lobe of the right lung was removed with perfect success ; in another, the lower half of the inferior lobe of the right lung was re- moved, by transversely cutting out a wedge-shape portion of tissue. The edges of the visceral pleura were coaptated. Au- topsy showed the operation to have been a success. In another experiment, a perforation was made, and the perforated area was sutured, and the lung replaced ; the dog recovered. Again, a lobe was punctured through its centre with a knife; perfect recovery resulted. In still another case, one-third of the in- ferior lobe of the right lung was cut away transversely. The dog recovered in a remarkably short time. Several experi- ments were made by puncturing the lung, and, also, by remov- ing parts, or, the whole of a lobe. In all cases the operations were successful. Once two ribs were resected, in order to Plate LXXIX. Pneumonopexy. Experiment on Lnngs, No. 25, page 491. THE LUNG OF THE DOG 473 reach the upper lobe of the right king. This, too, proved suc- cessful. It has been found during these experiments, that all cases of simple incision of lung, when returned to the cavity without suturing, have recovered. Unless a lacerated lung has been sutured previously to being returned to the thoracic cavity, the cut surfaces have become adherent to the parietal pleura, at the point of normal apposi- tion. But when it has been sutured before being returned, the lung has healed without pleuritic adhesions. It was also found, that after a lung had receded upon open- ing the chest, the probabilities are, that it will never regain its original distention, if a permanent opening be left in the chest wall, and adhesions are not formed. The removal of the superior border of any lobe was more easily accomplished than the removal of the inferior border of any lobe. In no case were clots found in the post mortems. Air will re-enter compressed lung tissue if the pressure be not too great, or sustained too long. In each case, where a portion of a lung was excised, the remaining portion of the lung became distended sufficiently to occupy the entire pleural cavity. Acceleration of respiration and circulation, immediately after operation, was remarked in all cases, the degree varying with amount of lung tissue excised, and the consequent loss of lung capacity. This was true whether it was a case of re- moval, or simple occlusion by ligation, or otherwise. The stomach was not distended with gas in all cases of in- fection. Large dogs withstood the operation better than smaller and younger dogs. The lungs were the only organs examined microscopically after autopsy. PIL\CTICAL HINTS AND THEORETICAL CONSID- ERATIONS, DEDUCED AND SUGGESTED BY THESE EXPERIMENTS This series of experiments corroborates the conclusions to be drawn from the reports of cases, and operations for lesions of the lungs. The surgeon should never hesitate to operate, if other meas- ures fail. There should be no hesitation, even though the case seems particularly desperate. There is much greater prospect of success in operating for all forms of pulmonary disease than some writers would have us think. Tait claimed that deductions from experimental operations on dogs, or other deep and narrow-chested animals, were mis- leading. These experiments, however, prove that surgical in- terference in pulmonary troubles is far from being impractical, or unjustifiable. The reason offered for decrying the applica- tion of the results of experiments, is based on the fact that only healthy animals or organs are operated upon. The experiments which form the basis of these remarks were made on such dogs as could be obtained. No effort was made to secure healthy dogs. Even when several dogs were obtained at the same time, the dog first at hand was used with- out making any selection. On account of several reasons (which are not germane to the subject) no special care was exercised in the performance of the operations ; neither did the dogs receive any particular care after the operations. Anti- septic precautions were generally neglected, too. Hence the results obtained under such circumstances are all the more re- 474 Plate LXXX. Experiment on Lungs, No. 26, page 491. / PRACTICAL HINTS AND THEORETICAL CONSIDERATIONS 4/5 markable. It is fair, therefore, to assume that if the same operations had been performed on human subjects, the results would have been as good, if not better. For in making such operations on human patients, greater care would have been exercised, and greater precautions observed to secure asepsis. These experiments showed that stab wounds bleed more than bullet, or similar wounds, unless important vessels be in- jured. The best mode of operating in these cases is to excise por- tions of the injured lung, and suture the cut edges, and it is better to excise portions of the apices of a perforated lung, when the wound is at the border, and suture the edges, than to attempt to close it with puckering sutures. In some cases, it m.ay be best to incorporate a portion of the lung into the chest wall, and relieve it later. A portion of one, or both pneumogastric nerves may be re- moved without danger, or permanent ill effect. The intimate connection of the vagus with other cranial or cerebrospinal nerves, and with the sympathetic, accounts for the danger from injuries to this nerve. It is impossible to separate the fibres of the one from the other. In case of an external laceration of a lobe, and if the con- trol of haemorrhage be impossible, or doubtful, it is safer to extirpate the lobe. This is the proper procedure in cases of certain forms of abscess, active destructive gangrene, or de- struction of a greater portion by necrosis. The character of a wound in the lungs is influenced by sev- eral factors, i.e., size of foreign body; velocity of missile; proximity to source of injury; character of chest wound, whether fracture or not; direction of missile; whether wound be received during inspiration or expiration ; environment ; and extent of injury to the vessels. In pulmonary operations, the incision should be made nearer the spine than to the sternum, as it will be easier to palpate, and deliver the lung. Perforating instruments should not be used 476 THE SURGERY OF THE LUNGS on lung tissue that is to be left in the chest cavity. It is bet- ter, too, to lacerate the lung, than to cut it, as there will be less bleeding. The less the amount of lung tissue incorporated in a ligature the better. In cases requiring the ligation of the bronchus : first, ligate the bronchus ; second, ligate the vessels, and dissect away the lung tissue. This must be done sooner or later. In ligating the bronchus, the ligature should be applied only after denuding the rings of mucous membrane. The bronchus may be closed by inverting its ends and suturing. Always cut or ligate transversely to the bronchial vessels ; parallel sections may be removed this way. When an entire lobe of a lung is removed, several ligatures should be used. The remaining portion of the lung should not be ligated "en masse," but only small portions of lung tissue should be incorporated in any one ligature. It is better to have too many than too few ligatures. The operator must be careful to make sure that the ligatures are drawn sufficiently tight, to preclude all danger of their dislodgement. Drainage is to be used in gunshot, incised and lacerated wounds. It is to be used in all cases of operation for abscess, gangrene and parasites. Counter drainage is only to be em- ployed when adhesion to the parietal pleura has not taken place. Drainage is just as important in operations on the thoracic or- gans, as in operations on the abdominal organs. In case of a punctured wound, do not be afraid of placing the sutures too deeply. In case a lobe has been removed, and, if for any reason, it is thought best to fix the stump in the intercostal space, the cu- taneous structures should be sutured over it, first having se- cured the blood-vessels and bronchi. Care must be observed to occlude the bronchia, that there may be no emphysema. These experiments proved that it is not always necessary to suture the lung tissue itself; ligating the blood-vessels and bronchia is sufficient. In such cases the lung will usually become adhe- PRACTICAL HINTS AND THEORETICAL CONSIDERATIONS 477 rent to the chest wall. In case blood should escape into the pleural cavity, no danger need be apprehended in traumatic injuries of the lung, if the removal of the damaged portion of the lung has been properly accomplished. Trauma, from forceps in grasping the lung, will produce sub-pleural cedema. This appears soon after the operation, when a portion of the lung has been extirpated. Hence flat forceps, with rubber coverings, should be used to grasp lung tissue, and the forceps should not be removed, until this portion of the lung is removed, or the operation completed. If a lobe be badly lacerated, by a piece of shell or otherwise, it is infinitely safer to remove the lobe, after having transfixed it to its base, or to the undisturbed tissue, than to do anything else. It is also better to allow an injured lobe or lung to remain contracted with an open chest wall, than to close the chest with gauze packing. In the latter case the lung will become dis- tended, and thereby ceases to be at rest, a condition most favor- able for the repair of any tissue. This is especially true of the lung, because the lung alternately expands and contracts upon itself from twenty to fifty, and even more, times per minute in severe injuries. If the lung can be kept quiescent w^ith an open chest for twenty hours, it is very probable that it will be- come safely distended with air when the chest wall is closed. In cases of wounds of the chest wall involving the lung, this retraction of the lung always occurs. The retraction of the lung favors the stoppage of haemorrhage, because it causes a forcible contraction of the blood-vessels ; a clot is formed, which stops the bleeding. But when the external wound becomes closed, by the formation of a clot, or otherwise, the lung will suddenly expand. The force exerted by the expansion of the lung, under these circumstances, is greater than in normal ex- pansion. The pressure thus suddenly exerted forces the clot out, and the haemorrhage will be renewed. This will occur again and again, until the wound finally heals. If immobility 478 THE SURGERY OF THE LUNGS can be maintained for a few days, or a week, there will be no question of recovery. There is, apparently, no limit to the degree to which the lung may be compressed. There have been no accurate obser- vations made on this point. It can hardly be determined ex- perimentally, because animals cannot be kept sufficiently quiet except by the use of anaesthetics, or by force. In either case the validity of the results obtained would be questionable. Anaesthetics, if they did not cause death, would, very likely, cause complications that would vitiate results. The use of force would defeat the very object which it was intended to secure. Hereafter, no doubt, greater care and accuracy will be employed in making observations on this point in man. In case the apex of a lung is lacerated, or incised, while distended, and the laceration, or incision, is not over three inches in length, it is safer to allow it to be undisturbed, espe- cially if there is no bleeding. It may become adherent to the parietal pleura, but this is better than to cause additional in- jury by an attempt to suture. The treatment of an injured bronchus depends upon the character of the wound; whether the laceration, or incision, be transverse, or longitudinal to the bronchus. If the bronchus has been opened for the purpose of making an exploration, it is the practice of some to pack instead of suturing. But this pro- cedure is not advisable if it is necessary to divide the bronchus transversely, because of the possibility, and probability, of end to end anastomosis not occurring. In all cases where the bronchus is severed transversely, and in cases of longitudinal wounds produced by injury, it would be better to suture, apply- ing the same methods as are used in similar wounds of the in- testines. It is a question whether it would not be safer to suture all wounds of the bronchus. A stout, healthy, normal dog can withstand the removal of either the right or left lung, entire. This has been done with the left lung in one of these experiments. Plate LXXXI. Experiment on Lungs, No. 27, page 492. PRACTICAL HINTS AND THEORETICAL CONSIDERATIONS 479 The removal of one or more lobes of a healthy, normal lung is likely to produce more serious results than the removal of one or more lobes of a diseased lung ; for, during the progress of the disease, there has been a gradual loss of lung capacity, propor- tional to the extension of the disease; while the loss of lung ca- pacity following the excision of one or more lobes of a healthy lung is sudden. In cases of this kind, the remaining portion of the lung will expand, and together with the diaphragm fill the space originally occupied by the whole lung. Of course, a part of a lung cannot perform the functions of a whole lung. Just how large a portion of a lung must be left, in order that the cav- ity may be filled by the expansion of this remnant together with the upward movement of the diaphragm, is not exactly known. The alveoli may be expanded to almost any degree, but from experiments, it has been determined that the alveoli lose their elasticity when excessively dilated. The loss of elasticity causes a cessation of function. The exact amount of lung tis- sue that may be lost, without causing loss of function in the remaining portion of the lung, has not been accurately deter- mined. It is a question, too, whether this expansion for the purpose of helping to fill the space occupied by the whole lung, in compensation for the lost portion, does not cause a diminu- tion of function. It is extremely probable that there is a de- crease of function in the mutilated lung greatly out of propor- tion to the amount of lung tissue lost. It is probable that if a lung were excised lobe by lobe, in suc- cessive operations, that the mortality would be much less than if the entire lung were removed in one operation. If sufficient time is permitted to elapse between each operation, for recovery from the preceding, it is probable that the shock would be less with each successive operation. It is very probable that the percentage of recoveries, from the excision of one or more lobes of a diseased lung, would be greater than the percentage of recoveries from the excision of one or more lobes of a healthy lung. 480 THE SURGERY OF THE LUNGS In case of a wound of the lung, or when there are grounds for supposing the lung to be injured, the patient should not be disturbed in order to make a positive diagnosis. Immobility, and quietude are absolutely essential in all wounds of the lungs. No man is infallible — even with all the aids provided by modern science, it is not always possible to make a positive di- agnosis. At times, diagnostic signs, which almost always in- dicate certain conditions, are misleading. Some of the most prominent and experienced surgeons have had such experiences. The success or failure of pulmonary operations centre about the kind of sutures, and the kind of material employed. There has always been controversy over the kind of mate- rial that should be used for ligating and suturing. Absorbable and nonabsorbable suture materials have their advocates. It is true that there are operations, the success of which will be more assured by the use of absorbable suture material ; there are other circumstances when it would be better to use non-absorbable material. It is only by experience, combined with a thorough knowledge of the anatomy, physiology, etc., of the tissues in- volved in the operation, that one is enabled to make the proper selection of material, and kind of suture to employ. Many pulmonary operations have, no doubt, been failures because wrong selections have been made of the kind of material used in suturing, or the wrong kind of suture used, or both. Failures have been caused also, by sutures being placed too near the lips of the wound, or by the punctures of the needle being too close together. It is better to have too few sutures than too many, but with regard to ligatures it is better to have too many than too few. When an antiseptic ligature is placed in aseptic tissues, there is no destructive change to weaken the vessel walls, therefore the ligature should include a minimum amount of vascular tis- sue, and should never be applied in such a way as to lacerate the walls of an artery. The best needle for lung surgery is a coarse, blunt one, just PRACTICAL HINTS AND THEORETICAL CONSIDERATIONS 48 I large enough to take whatever material is selected for suturing. By the use of a blunt needle, the danger of wounding the deli- cate vessels and bronchia which ramify through the lung, is reduced to a minimum. The puncture of a needle should not be closer than one-half inch to the margins of the wound. All stumps of lung tissue should be secured by transfixion ; that is, the needle armed with kangaroo tendon should be passed through the thickness of the lung, and tied. It is a combina- tion of ligature and suture. At times it is not advisable to suture, and in such cases, a clamp or clamps should be applied. The clamp may be al- lowed, if necessary, to protrude through the opening in the chest wall. Under no circumstances should torsion or acupressure be employed to secure blood-vessels in the lungs. In all cases of chest wounds involving the lung, the lung will retract. It will also retract on an attempt to suture it, if it is not already re- tracted ; but as soon as the external chest wound is closed, the lung will immediately expand with greatly increased force. Torsioned vessels will give way to a force of one-half an atmos- phere, in addition to the normal blood pressure ; vessels, secured by acupressure, will not withstand a force of one atmosphere in addition to the normal blood pressure. The force exerted by the sudden expansion of the lung, under the above circum- stances, will amount to at least two atmospheres. Ligation is the only method of securing blood-vessels that will sustain this pressure. Do not place sutures near the edges of a wound, especially 'if it is an incision. If there is haemorrhage, ligate the bleeding- vessels by transfixion. The " concealed," or *' interrupted " sutures should never be used in operations on the lung. If fine suture material is used, or if sutures are placed too close together, or too near the edges of the wound, the sutures 482 THE SURGERY OF THE LUNGS will tear out. Fine material, even if placed at the proper dis- tance from the margins of the wound, will cut the lung tissue. For all purposes, kangaroo tendon is the best material to employ for suturing the lung ; because of its relatively large size, the su- tures may be placed farther apart, and may also be tied more tightly without danger of cutting the lung tissue, and the swell- ing caused by absorption of serum will aid in preventing bleeding. This series of experiments demonstrates certain kinds of sutures to be more suitable than others. Among those that proved of special value were the " whip-stitch," which is simply an over and over continued suture; the "tug-stitch"; the " continued " suture ; the " mattress " or " quilted " suture; the " glover's " suture; the " lace," and " Bell's." The whip-stitch is to be used in simple superficial incision, or lacerations. The ordinary continuous suture is also useful for the same purpose. A combination of the mattress and con- tinuous sutures is useful in extensive superficial incisions, and lacerations. The glover's is best adapted for incisions near the base of the lung, as it will keep the margins of the wound from everting. The Bell suture is best adapted for wounds in those parts of the lung where there is the least strain from the activ- ity of the lung. The herringbone stitch is also of great utility in preventing the lips of a wound from everting. The mat- tress, or quilted suture is best adapted for deep incisions, or lacerations which do not extend through the entire thickness of the lung. The tug-stitch is the only suture that will answer in case of an incision, or laceration extending through the entire thickness of a lobe at its base; in other words, when a lobe is split. This suture is only an adaptation of the saddlers' stitch," which he employs in sewing a trace, etc. Two needles are used ; one is passed through the entire thickness of the lung, at a dis- tance of one-half inch from the lip of the wound; it emerges posteriorly, on the same side of the wound as it entered. The second needle is passed from the posterior surface of the lung, Plate LXXXII Experiment on Lungs, No. 28, page 492. PRACTICAL HINTS AND THEORETICAL CONSIDERATIONS 483 through the entire thickness of the king ; it emerges anteriorly through the puncture made by the first needle. The puncture of the second needle is made on the same side of the wound as that of the first needle. Then the second needle is passed, still on the same side of the wound, from the anterior surface of the lung, through the entire thickness of the lung, to the posterior surface, and there emerges, on the same side of the wound as it entered. The first needle is then passed through the puncture, just made by the second needle, to the anterior surface, where it emerges from the opening made by the entrance of the second needle. This procedure is continued until this side of the wound has been sutured in its entire length. Then the other side of the wound is sutured in the same manner. The author devised a suture which he found to answer bet- ter than any other for cases where the wound was caused by a puncture, or perforation, and a piece of lung tissue had been torn out. This suture is a combination of the lace and tobacco-pouch, or tug-stitch. A single curved needle is used. The needle is dipped rather deeply into the lung tissue about one-half inch from the edge of the wound, then it is made to emerge about one-half inch from place of entrance ; this procedure is repeated until the entire wound is encircled with sutures. Then a sec- ond row of sutures is made ; each stitch of the second row being- so placed as to alternate with the first. In other words, where- ever the kangaroo tendon, of the first row of sutures, is on the surface of the lung, that of the second row will be below the surface. By this means the wound is not only entirely encircled by sutures, but the tissue, surrounding the perforation, is com- pressed. This compression of the tissues also compresses the vessels, which have been severed, and the haemorrhage is stopped. DESCRIPTION OF PLATES I AND LVII TO LXIII PLATE I This plate gives an anterior view of the heart and lungs, in situ, of a dog weigh- ing about forty-five pounds. The arteries, veins, and bronchia were injected with starch. This procedure completely distended the organs, and caused them to assume, and retain the shape of the thoracic cavity. The most striking feature, perhaps, which reveals itself at a first glance, is how nature provides protection for the most important organs. It shows that the right upper lobe of the lung overlaps the entire upper portion of the heart, while the left upper lobe affords like protection to the other side; the middle lobe too closes in around the heart, thus forming a natural, living air cushion, to ward off injuries, and sudden shocks to the heart. The right upper lobe (i) extends across the upper part of the chest, meeting the left upper lobe. At (2) is the right middle lobe (the cord seen, is a rubber band used to hold the lungs while being photographed). Immediately below is shown the curled edge of the right lower lobe (3); this lobe is much larger than the others. In fact, it appears as if the right, middle lobe (2) was but a process of the right lower lobe. Just below the right middle lobe, is seen a cord; this is the end of a ligature around the aorta. The heart is shown in its nest-like surroundings at (5). The left upper lobe (6) overlaps the right upper lobe, completing the air-cushion-like protection of the heart. The left middle lobe (7) overlaps the upper (6) and lower (8) lobes, thus filling the space between the two. The white spots are caused by the escape of some of the starch, used to inject the vessels. PLATE LVII This plate gives a posterior view of the same organs shown in plate la. The arteries, veins, and bronchia are distended with starch. The left upper lobe is shown at (i). The thoracic aorta (2), is clearly seen, together with its intercostal branches. The latter are placed in pairs, opposite one another. The left lower lobe (3) extends more toward the neck but not as low down as does the right lower lobe (7). The bronchial gland (4) is well brought out in the plate. Only a point of the right middle lobe (6) can be seen in this view. The right upper lobe (5) extends higher toward the neck, and not so far down as does the corresponding left lobe. PLATE LVIII A TRANSVERSE SECTION OF THE LOWER LOBES The posterior aspect is shown at (6). The white spots are caused by the exud- ing of the starch with which the vessels were injected. The lower wing of the butter-fly lobe (i) is shown resting on a rubber band. (2) The left middle lobe. (3) Apex of the heart. 484 DESCRIPTION OF PLATES 485 (4) The right middle lobe. (5) Upper wing of butterfly lobe.. As has been remarked, in explanation of Plate la, the lung forms an air-cushion- like protection to the heart anteriorly, while it is partially protected in the same way posteriorly, in addition to the support, and protection afforded by the spined column and ribs. PLATE LIX A, TRANSVERSE SECTION OF THE LOWER LOBES, TOGETHER WITH THE LOWER WING OF THE BUTTERFLY LOBE, AND APEX OF THE HEART The white spots in this plate, as in all the others, are due to the starch escaping from the various vessels. (i) The oesophagus; just above, is seen one of the mediastinal vessels. (2) A transverse section through apex of the heart. (3) Section of lower wing of butterfly lobe. (4) The upper vdng of butterfly lobe. PLATE LX A POSTERIOR VIEW OF A TRANSVERSE SECTION OF THE LOWER LOBES (i) A section of the bronchus. (2) Section of a bronchus in the body of the lung. (3) Section of heart. (4) A venesection. (5) The bifurcation of bronchus in right lower lobe. (6) End of middle lobe. (7) End of middle of butterfly lobe. (8) The oesophagus. PLATE LXI-A FOURTH POSTERIOR VIEW (1) Section of left middle lobe. (2) CEsophagus. (3) Left upper lobe. (4) Section of left bronchus. (5) Section of the right upper lobe. (6) Part of right upper lobe. PLATE LXI-B FIFTH POSTERIOR VIEW (i) Arch of the aorta, distended with starch. (2) The great pulmonary vein. (3) Portion of the left upper lobe. (4) The thoracic aorta. (5) Portion of heart. (6) The oesophagus. (7) The trachea, from which the starch is exuding. (8) Under side of the right upper lobe. 486 THE SURGERY OF THE LUNGS PLATE LXII-A SIXTH POSTERIOR VIEW (i) Section of the left upper lobe. (2) The left bronchus. (3) The oesophagus. (4) The trachea, partially injected, (s) Section of the right upper lobe. PLATE LXH-B (i) The posterior aspect of the main bronchus. (2) The oesophagus. (3) Trachea, partially injected. (4) Section of the right upper lobe. (5) A section of the left upper lobe. PLATE LXIII A POSTERIOR VIEW OF A TRANSVERSE SECTION OF THE LOWER LOBES, FROM A STILL DIFFERENT ASPECT (i) Extreme end of the left upper lobe. (2) The oesophagus. (3) Section of the trachea. (4) Extreme end of the right upper lobe. Plate LXXXill. Experiment on Lungs, No. 30, page 492. RECORD OF EXPERIMENTS 1. June 30, 1900. — Black curbstone setter; weight, 20 pounds; age, 8 months. Right side of chest. Death occurred while operating. Autopsy made one hour later. No special cause of death discov- ered, probably due to anaesthetic. Specimen was not photographed, because of no special interest. 2. July 8, 1900. — Water spaniel bitch, one year old; weight, 22 pounds. At II A.M., one-third of inferior lobe of right lung removed through the fifth intercostal space after resection of fifth rib, and stump of lung anchored to chest wall. All tissues sutured with silk-worm gut, and stump covered with skin. Dog died at 10:30 a.m., July 12, 1900. Autopsy. — Pleural cavity was filled with pus; all organs appeared normal. Death due to exhaustion, from infection. Stump of lung, soft, and adherent to the chest wall. Infection probably due to want of caution, while chest cavity was open. 3. July 10, 1900. — Bitch, 3 months old; weight, 10 pounds. In- ferior lobe of right lung removed, after ligating the bronchus, and vessels at base, with silk without transfixion (purposely). Thirty minutes after operation respiration registered 80 per minute; pulse, very rapid. Death occurred July 19, 1900. Autopsy showed perfect repair in stump ; exhaustion, from infection, was the probable cause of death. 4. July 19, 1900. — Cur dog, one and a half year old; weight, 20 pounds. Inferior lobe of right lung removed, and stump ligated with silk by transfixion, and chest closed by silk-worm gut. Death occurred at 7:30 A.M., July 2 1 St. Autopsy. — Liver much enlarged; gall bladder greatly distended with bile; stomach was also distended with gas. The ligature around stump had cut through a mass of lung tissue, which had by accident been included within it. Pleural cavity on right side contained six ounces of bloody fluid, indicating that death was probably due to a slow haemorrhage, from an imperfectly ligated stump. There were no adhesions of the parietal with the visceral pleura. The ends of the silk-worm gut are to be seen in the photograph. (Plate LXIV.) 5. July 20, 1900. — Common cur bitch, seven months old; weight 30 pounds. A silk ligature was appHed to one-half of middle lobe of 487 488 THE SURGERY OF THE LUNGS right lung, after having deUvered it through the chest wall with forceps. The transfixed, and ligated portion of the lung was cut away with scis- sors. There was no haemorrhage from the stump, which was returned to the pleural cavity. Death, July 22, 1900. Autopsy. — The ligature had cut through stump, allowing about five ounces of blood to escape into the pleural cavity. Death was due to exhaustion from haemorrhage. No doubt, the amount of blood contained within the pleural cavity had been lessened by constant absorption. 6. July 20, 1900. — Common dog, six years old; weight, 30 pounds. A kangaroo tendon was passed through one-half of lower lobe of left lung, close to bronchus, allowing the incorporated mass to remain. Closed wall with silk-worm gut. Dog died during the night of July 23, 1900. Autopsy showed ligature to have escaped by sloughing of stump; there was also general pleurisy and about half a pint of flocculent pus. A white pleuritic membrane extended over the entire visceral and parietal pleura, upon the left side. (Plate LXV.) 7. July 20, 1900. — Bulldog, one year old; weight, 40 pounds. The same procedure as in No. 6, except that the middle of the upper lobe of the right lung was ligated, by throwing a kangaroo tendon around the middle of the lobe, including the bronchus, the lumen of which was occluded. None of the strangulated portion of the lung was removed. The chest wall was closed in the usual way. The dog was killed on the ninth day following the operation. (Plate LXVI.) Autopsy demonstrated the perfect repair of the lung. There were pleuritic adhesions, here and there, in both the right and left sides, those upon the right having occurred subsequent to the operation. The age of those upon the left side was doubtful. The photograph shows the perfect union. The large white spot is the cicatrix. 8. July 21, 1900. — Black mongrel dog, one year old; weight, 20 pounds. The inferior lobe of the right lung was divided by the knife, for two-thirds of its length; no special bleeding. The edges of the wound were coaptated, using the glover's suture through and through, and lobe returned to the pleural cavity. The dog was killed nine days after the operation. Autopsy revealed perfect repair, with adhesions of the visceral to the parietal pleura. The denuded lung was found adherent to the chest wall, at its proximity, during normal expansion. The illustration shows the point of perfect repair. (Plate LXVII.) 9. July 21, 1900. — Brown cur, one year old; weight, 14 pounds. The butterfly lobe of right lung was removed; silk-worm gut was used for ligature, and also to close the chest. The lower lobe was consider- ably lacerated with forceps, in an endeavor to deliver it for attack. Dog died 4 p.m., July 24, 1900. Plate LXXXIV. ExpERiAiEMT ON LuNGS, No. 31. page 492. RECORD OF EXPERIMENTS 489 Autopsy. — Right pleural cavity contained four ounces of purulent pleuritic effusion. No pleuritic adhesions present. Death probably due to infection. 10. July 21, 1900. — Brown water-spaniel, one year old; weight, 20 pounds. A portion of the fifth and sixth ribs upon the right side was removed with forceps. The lung was then exposed, and forceps thrust through the entire thickness of the lung, near the base of the inferior lobe. A piece, about the size of a silver quarter, was torn from the centre of the lobe. The opening was closed by the pucker- ing, or lace suture, using silk-worm gut. The entire circle was trav- ersed, by passing the needle back and forward. The lobe was returned to the pleural cavity, and opening in chest wall closed with silk-worm gut. (Plate LXVIII.) • II, July 22, 1900. — Black spaniel, eight months old; weight, 18 pounds. The lung was exposed, and an incision, one and a half inches long, made in the superior lobe of right lung. The lung was then returned to the pleural cavity, without suturing, or any other attention, and the chest wall closed. Autopsy, seven days after operation, showed perfect repair, with adhesions of visceral and parietal pleura. The edges of the wound united nicely. There was only a Hne-hke cicatrix. (Plate LXIX.) 12. July 22, 1900, 7 A.M. — Common cur, eight months old; weight, 22 pounds. The inferior lobe of the right lung was removed. Silk- worm gut was used to ligate the stump, which was transfixed. The dog died thirty-six hours after the operation. Autopsy. — There were found one and a half pints of bloody serum in the right pleural cavity. Stump was found to be in good shape, except a small portion of the lung, which was not incorporated in the ligature. Death, probably due to haemorrhage, from non-incorporated portion of the lung. 13. July 24, 1900. — Mixed bull, one and a half year old; weight, 35 pounds. At 6:30 A.M., removed one-half of the inferior lobe of the right lung, using kangaroo tendon for tug stitching. The chest wall was closed with silk-worm gut. August 9th the dog was killed. Autopsy revealed complete recovery and perfect repair. (Plate LXX.) 14. July 24, 1900. — Fox-terrier bitch, one and a half year old; weight, 15 pounds. Removed inferior lobe of right lung, by tying stump in three sections. The vessels were first ligated at the base, with silk-worm gut on either side of bronchus. The bronchus was then occluded by silk-worm gut. Killed dog August 9th. Autopsy showed that repair was far enough advanced to assure the preservation of life. The illustration shows stump, and silk-worm gut ligature, firmly fixed in the lung tissue. (Plate LXXI.) 15. July 24, 1900. — Fox-terrier bitch, age ten months; weight, 12 pounds. Cut off portion of inferior lobe of right lung with knife; 490 THE SURGERY OF THE LUNGS silk-worm gut was used for Bell sutures. Stump was fixed in the inter- costal space; edges of the integument were sutured, to allow the lung stump to be exposed. Dog died on the seventh day. Autopsy showed pneumonia of middle, and butterfly lobe of right lung. i6. July 26, 1900. — Tall dog, two years old; weight, 50 pounds. Removed inferior lobe of right lung; using kangaroo tendon and silk- worm gut to whip-stitch stump. Dog killed on fourteenth day after operation. Autopsy revealed perfect repair of stump, and complete recovery. A portion of silk-worm gut, and a small piece of kangaroo tendon were seen — the latter was in process of disintegration. The photo- graph shows all these features. (Plate LXXII.) 17. July 25, iQoo.^Black mixed spaniel; age, one year; weight, 25 pounds. Removed entire inferior lobe of right lung, using trans- fixed, braided silk for tug suture. Death six days later. Autopsy showed open stump. The ligature had been drawn tight enough about the lung tissue, which was degenerated. Although the ligature was loose, the bronchus had become occluded. No satis- factory explanation for cause of death could be formed from appear- ance of the organs, since they all seemed normal. 18. July 25, 1900. — Gray shepherd dog, one year old; weight, 25 pounds. Removed the lower two-thirds of inferior lobe of the right lung by cutting, transversely, a wedge-shaped portion of lung tissue. This was done, to allow the edges of the visceral pleura to be coaptated, first with catgut, and then with kangaroo tendon. The right pleural cavity was packed with gauze, one end of which was allowed to protrude out of the chest wall. Dog died five days later. (Plate LXXIII.) Autopsy did not reveal the cause of death. It was probably due to infection. The gauze was slightly discolored with serum; no pleu- ritic adhesions; no pus in pleural cavity. Repair of stump had been progressive, as shown by the complete absorption of the catgut, and union of coaptated edges of the divided lung tissue. This case well illustrates the comparative life of cat-gut, and kangaroo tendon. 19. July 25, 1900. — White terrier bitch, one year old; weight, 15 pounds. Chest wall opened, and a pair of large forceps thrust through the inferior lobe of the right lung. There was but Httle haemorrhage. Kangaroo tendon used for tug stitching. The suture used was not ex- actly the tug stitch, but the one devised by the author. It is a com- bination of the tug and lace sutures. In this case, the wound was completely encircled by a double row of sutures. Only one needle was used. (See Section on Sutures in Part I.) Autopsy showed complete recovery, and repair, leaving a small, hard, white cicatrix, extending through the lobe, which was apparent to the sense of touch. The photograph plainly depicts the hard, white, circumscribed cicatrix. (Plate LXXIV.) Plate LXXXV. Experiment on Lungs, No. 33. page 492. RECORD OF EXPERIMENTS 491 20. July 30, 1900. — Black terrier, ten months old; weight, 12 pounds. The left lower lobe of the right lung was punctured and lacerated, using both knife and finger. Kangaroo tendon was employed to circumscribe the wound, with the author's combination suture. Killed dog nine days after the operation. Autopsy showed perfect and uneventful recovery, with complete repair of the lung. The photograph shows how perfectly the wound united, and the very shght cicatrix formed. (Plate LXXV.) 21. July 30, 1900. — White terrier, ten months old; weight, 15 pounds. At 5:30 A.M. cut away one-third of the inferior lobe of the right lung, transversely; using kangaroo tendon to whip-stitch the wound. Killed dog nine days after the operation. Autopsy showed complete repair of the stump, as seen in photo- graph. (Plate LXXVI.) 22. July 30, 1900. — Black fox-terrier, one year old; weight, 15 pounds. Punctured inferior lobe of right lung, and tug-stitched in a circle around the perforation. The Bell suture was used in tug-stitch- ing, and the sutures were passed through the entire thickness of the lobe. Killed dog nine days later. (Plate LXXVU.) Autopsy showed perfect union, with a light-colored cicatrix. 23. July 30, 1900. — Black terrier bitch, one year old; weight, 15 pounds. At 5:30 A.M. cut away transversely one-third of butterfly lobe of the right lung; kangaroo tendon used to tug-stitch the wound. Killed dog August 9th. Autopsy. — There was perfect repair of stump, but with adhesions to the chest wall, at the point of normal proximity, at time of maximum inflation. 24. July 30, 1900. — Mixed fox-terrier and water-spaniel, one year old; weight, 15 pounds. Removed one-half of the middle lobe of the right lung. Kangaroo tendon was employed in suturing. Autopsy, nine days later, revealed perfect repair and union of stump. The photograph shows appearance of lungs. (Plate LXXVUI.) 25. July 30, 1900. — Yellow cur bitch, one and a half years old; weight, 18 pounds. Right upper lobe brought into opening in the chest wall and cut off. Stump was fixed in the intercostal space, with silk-worm gut. The cutaneous structures were sutured over it. Killed dog August 9th. Autopsy showed perfect recovery and union (Plate LXXIX), with stump firmly adherent to the chest wall, at point of fixation. 26. July 30, 1900. — Black and white cur dog, one year old; weight, 60 pounds. Removed inferior lobe of right lung, after silk-worm gut had been applied for ligature. The ligature became dislodged, and death ensued within two minutes. Autopsy, ten minutes later, showed pleural cavity filled with blood. 492 THE SURGERY OF THE LUNGS The vessels and bronchus were open. Death was due to haemorrhage, as a result of carelessness. (Plate LXXX.) 27. July 30, 1900. — White bulldog, two years old; weight, 45 pounds. Same operation with the same results as in No. 26. Death caused by haemorrhage, due to carelessness. (Plate LXXXI.) 28. July 30, 1900. — Black dog, two years old; weight, 50 pounds. One-half of upper lobe of right lung was cut away, transversely, using silk to whip-stitch. Silk was also used to ligate both vessels, and bronchus. Dog died August 9th. Autopsy showed right side of pleural cavity tilled with bloody serum. Death probably the result of stump opening in line of suture. This was caused by imperfectly applied ligature. (Plate LXXXII.) 29. August 6, 1900. — Fox-terrier, six months old; weight, 12 pounds. The inferior lobe of right lung was split and returned to the pleural cavity, without suturing the divided portion of the lung. The chest opening was closed with silk-worm gut. Killed dog August 14th. Autopsy showed perfect repair of lung, with adhesion to chest wall, at the point of normal proximity, at time of maximum expansion. 30. August 2, 1900. — Maple cur, two years old; weight, 18 pounds. Removed upper lobe of right lung, after resecting the fifth and sixth ribs. Kangaroo tendon used for ligating, by transfixing at base of lung. Killed dog August 14th. Autopsy showed repair of stump to be perfect. (Plate LXXXIII.) 31. August 2, 1900. — Black dog (No. i), one year old; weight, 20 pounds. At 2 P.M., ligated base of right wing of butterfly lobe, by transfixing with kangaroo tendon. Killed dog August 14th. Autopsy revealed perfect repair, with kangaroo tendon covered with plastic material. (Plate LXXXIV.) 32. August 2, 1900. — 3 P.M. — Black dog (No. 2), one year old; weight 20 pounds. Applied tug-stitch, for three inches across the upper lobe, through the entire thickness of the lung, with silk. Killed dog August 9th. Autopsy showed the silk suture almost entirely covered with new tissue. Recovery and repair perfect. 33. August 2, 1900. — Yellow black-nosed dog; two years old; weight, 25 pounds. Applied sutures, using silk ligature, across the upper right lobe of the lung, near its centre. (The herring-bone suture was the one em- ployed here.) Killed dog August 9th. Autopsy showed perfect recovery from operation, and repair of lung. The end of the silk was exposed. (Plate LXXXV.) 34. August 2, 1900. — Bobtail dog, ten months old; weight, 14 pounds. Removed upper lobe of right lung, using kangaroo tendon for three liga- tures at the base. The kangaroo tendon was used to transfix the base. The first ligature was placed around all the vessels; the second occluded the bronchus, and the third, the lung ti.s.sue. Killed dog August 9th. Plate LXXXVI. Experiment on Lungs, No. 34, page 492. RECORD OF EXPERIMENTS 493 Autopsy showed perfect recovery, and repair of stump. (Sec Plate LXXXVI.) 35. August 2, 1900. — Black dog, two years old; weight, 25 pounds. Lower lobe of right lung was split perpendicularly, and sutured with kangaroo tendon, using a relief suture (mattress). Killed dog August 14th. Autopsy showed complete recovery, and perfect repair. Point of re})air adherent to chest wall at the point of proximity, at time of maxi- mum inflation. 36. August 2, igoo. — Fox bitch, one and one-half years old; weight, 18 pounds. Resected the sixth rib on the right side, leaving the pleural cavity open fifteen minutes. The mediastinum was then incised near the heart, thus allowing the left lung to recede. Both cavities were ex- posed to atmospheric pressure for five minutes. The opening in the chest wall was covered by the hand. Respiration was again estab- lished, and lungs allowed to recede. There was more or less motion of the lungs while the chest remained open. At the end of twenty-five minutes the opening of the chest wall was closed with silk-worm gut, and dog sent to his kennel. Killed dog August 14th, 4 p.m. Autopsy showed nothing abnormal. The mediastinum was closed, and repair complete. 37. August 2, igoo. — Dark brown dog, eight months old; weight, 16 pounds. This dog died as the chest was being opened. Autopsy gave only negative results. No cause of death discovera- ble; probably due to ether. All the organs were normal and in good condition. 38. August 6, igoo. — Common dog, eight months old; weight, 12 pounds. Apex of lower lobe of right lung cut away. The bleeding vessels were torsioned, and the lung returned to the pleural cavity, with- out the lung tissues being sutured. Killed dog August 14th. Autopsy showed complete recovery, and repair of the lung, but the lung was adherent to the chest wall at point of normal proximity, at time of maximum expansion. 39. August 6, igoo. — Long-haired dog, one year old; weight, 25 pounds. Removed butterfly lobe, using kangaroo tendon for each liga- ture, at base. The first ligature was placed around the blood-vessels; the second around the bronchus; the third was placed about the lung tissues. On the tenth of August the dog attempted to escape, and the attend- ant seized him rather roughly by the back. This caused the chest wall to open; it was not again closed. The dog died at 6 a.m., August 13th. Autopsy showed the stump in a good state of repair. The pleural cavity contained some pus, the result of suppurative pleuritis. The bronchus and blood-vessels were found occluded. The infection prob- 494 THE SURGERY OF THE LUNGS ably occurred after the reopening of the chest cavity, which was pur- posely left open. There were no adhesions of the pleura. 40. August 6, 1900. — Black bitch, two years old; weight, 27 pounds. Divided the fifth intercostal artery, on the right side, to allow three or four ounces of blood to escape into the pleural cavity. The chest wall was closed with silk-worm gut. Killed dog August 14th, 4 p.m. Autopsy showed complete recovery. There were no clots, fluid, or adhesions found in the pleural cavity. 4:. August 6, 1900. — Hound bitch, five months old; weight, 10 pounds. Inferior lobe of right lung, split, and returned to the pleural cavity, without suturing the lung. Killed dog, August 14th. Autopsy showed union to be complete. The end of the lung was adherent, at its point of proximity, to the chest wall, at time of maxi- mum expansion. 42. August 14, 1900. — Chestnut dog, one year old; weight, 27 pounds. Resected the fifth and sixth ribs on the right side. Ligated, with silk, the vessels at base of the upper lobe of the right lung. A silk ligature was placed also about the bronchus. Removed two ounces of clots from the pleural cavity, which was open twelve minutes. Death occurred just as the cavity was being closed. Autopsy revealed no cause of death. It was probably due to ether. Neither air nor water could be forced through stump, proving that bronchus and vessels were occluded. 43. August 14, 1900, 3 P.M. — Black dog, six months old; weight, 24 pounds. Folded upper part of right lung upon itself, and sutured with silk, using the interrupted suture. This was done in order that the visceral pleura might become adherent. Dog died August 17th. Autopsy showed the lung in good condition. No fluid in cavity, nor any cause of death discoverable. The dog had distemper at time of operation, and but little attention was given him. 44. August 14, 1900. — Black dog, one year old; weight, 18 pounds. Divided sixth rib on right side, incised inferior lobe, transversely, to one-third of its thickness. Sutured with kangaroo tendon, employing the mattress, or quilted suture. Killed dog August 21st. Autopsy. — Lobe, at point of incision, adherent to the chest wall, at a point corresponding to the point of normal proximity at time of maxi- mum distention of the lung. The kangaroo tendon had broken into several pieces, but it still could be recognized. 45. August 14, 1900. — Brown dog, one year old; weight, 18 pounds. Killed dog with chloroform. Removed the lungs, and injected the bronchia with paraffin, while lung was in water, at a temperature of one hundred and twenty degrees F. The process was not at all satis- factory, however, as the paraffin occluded the bronchioles before dis- tention was complete. 46. August 14, 1900, 5 P.M. — White bitch, three years old; weight. Plate LXXXVII. Experiment on Lungs, No. 46, page 492. RECORD OF EXTERIMENTS 495 40 pounds. Amputated the upper right lobe. Braided silk was used as a ligature, to ocx'lude the bronchus alone, while another ligature, of the same material, was used to occlude the blood-vessel; each ligature being transfi.xed at base of the lung before it was made taut. Killed dog August 20th. Autopsy showed repair of stump, practically complete. All the vessels were found to be occluded. (Plate LXXXVII.) 47. August 25, 1900. — Black dog, one year old; weight, 15 pounds. Killed dog with chloroform, in order to secure the lungs. Injected bronchial, arterial, and venous systems with a mixture of anilin, starch, and formalin. Specimen unsatisfactory, owing to tuberculous de- generation of apex of the superior lobe of the left lung, which ruptured during injection. This is the only one, of the series of fifty dogs, in which any signs of tuberculosis were found. 48. August 22, 1900. — Black Newfoundland dog, five years old; weight, 50 pounds. Killed dog, in order to secure the heart and lungs. Injected bron- chial, arterial, and venous systems with starch and anilin, in formalin water (one per cent.). This specimen was divided with the knife, transversely, making seven sections, each one inch thick. Each section was photographed separately, as shown in Plates LVIII to LXIII. 49. August 27, 1900. — Hound bitch, three years old; weight, 35 pounds. Dog killed with chloroform, for specimen. Injected with starch and anilin, in formalin water, with satisfactory results. 50. August 25, 1901. — Fox terrier, one and one-half years old; weight, 18 pounds. Removed entire left lung. Dog recovered and lived, with no ill effects. Killed on eighteenth day. ANALYSIS OF TABLES An examination of the tables reveals the fact, that most of the deaths were avoidable. Seven dogs died from infection, which is about 15.7 per cent. Seven dogs died from haemorrhage (secondary and primary), or about 15.7 per cent. Lack of care on the part of the operator and attendants was responsible for all these cases of infection and haemorrhage. But, as stated in explanation of the experiments and results obtained, no special care was observed, nor were any antiseptics used. Some of the operations were performed hurriedly, and the operator was per- haps a Httle careless. This was shown by the autopsies. In one case the ligature had slipped, in another, the ligature had been dislodged, because the tissues broke down from infection. All this could have been avoided, by observing the principles of modern surgery. There remain only three deaths to be taken in account, in arriving at a just estimate of the mortality in pulmonary surgery. Of these three cases, one was due to pneumonia, and two to the anaesthetic. This case of pneumonia was probably due to infection; hence could have been avoided. It is also a question, just how far the operator is responsible for deaths from the anaesthetic. It will also be noticed that the majority of the deaths occurred dur- ing the early part of the series. In all kinds of experimental work on the living subject, there are numerous practical details that can only be solved by actual experience. So in this series, as the operator gained experience and skill in this work, he had better success. The needed experience is soon gained. If it were possible to repeat these experiments, there is no doubt that the mortality would be greatly reduced, even if deaths from in- fection, etc., were not completely eliminated. 496 ANALYSIS OF TABLES 497 SUMMARY OF RECOVERIES AND DEATHS RECOV- ERIES. DEATHS. PERCENT- AGE. From infection (average length of life, 51-7 davs) 7 2 5 I I 2 5 14 4 10 " Haemorrhage, primary (died on the table) " Haemorrhage, secondary (average length of life, three days) — imperfect ligature " Pneumonia " Accidental opening of wound " Anaesthetic 2 4 54 10 Killed for autopsy and specimen Killed for specimen of normal lung 28 23 Number of operations 46 28 18 Number of recoveries Number of deaths STATISTICAL REPORT OF LUNG SURGERY ON FIFTY DOGS (Experimental) Section No. i. Unsuccessful Results. CAUSE OF DEATH. TIME LIVED. CONDITION AT DEATH. I 2 3 4 5 6 9 12 15 17 18 26 27 28 37 39 43 Infective pleurisy General infection General infection General infection Secondary hcemorrhage Infection Infection Imperfect ligature Pneumonia Imperfect ligature . Infection Haemorrhage Haemorrhage Secondary haemorrhage Anaesthetic Accidental opening of wound Unknown ID aays. 4 days. 9 days. 2 days. 2 days. days. days. days. days. days. Died during operation. Died during operation. 3 days. 7 days. Discharging pus. Discharging pus. Discharging pus. Ligature slipped. - Clot in cavity. -Clot infected. Slough. Open wound (lung stump). Had distemper at time of ojiera- tion. 498 THE SURGERY OF THE LUNGS STATISTICAL REPORT OF LUNG SURGERY ON FIFTY DOGS (Experimental) Section No. 2. Successful Results. NO. WAS KILLED ON CONDITION. RECOVERY. 7 19th day. Perfect repair. Complete. 8 19th day. Perfect repair. Complete. 10 19th day. Perfect repair. Complete. II 19th day. Perfect repair. Complete. 13 1 6th day. Perfect repair. Complete. 14 1 6th day. Perfect repair. Complete. 16 14th day. Perfect repair. Complete. ^9 15th day. Perfect repair. Complete. 20 loth day. Perfect repair Complete. 21 loth day. Perfect repair. Complete. 22 loth day. Perfect repair. Complete. 23 loth day. Perfect repair. Complete. 24 loth day. Perfect repair. Complete. 25 loth day. Perfect repair. Complete. 29 8th day. Repair going on Complete. 30 12th day. Perfect repair. Complete. 32 7th day. Repair progressing. Complete. 31 12th day. Perfect repair. Complete. 33 7th day. Good. Going on. 34 12th day. Perfect repair. Going on. 35 1 2th day. Perfect repair. Complete. 36 12th day. Perfect repair. Complete. 38 8th day. Perfect repair. Complete. 40 8th day. Perfect repair. Complete. 41 8th day. Perfect repair. Complete. 44 7th day. Repair progressing. Complete. 45 6th day. Repair progressing. Complete. 46 Killed in order to se- cure lung for other pur- poses. 47 Ditto. 48 Ditto. 49 Ditto. 50 1 8th day. Perfect repair. Complete. INDEX Abnormalities, of bronchi, 289 of chest, 290 causes of, 289 of diaphragm, 289-292 of ductus arteriosus, 42, 47 of foramen ovale, 40, 42 of heart, abnormal number of cav- ities, 47, 78 extrophy of, 291 of interauricular openings, 42 of interventricular openings, 41-46 effect of, 41, 42 position of, 41 varieties of, 41 of lung, 289-292 aetiology of, 289 bibliography of, 292 cases reported, 290 diaphragmatic hernia, 290 three lungs, 292 of mediastinum, 289 of pericardium, 289 of pulmonary vessels, 289 of thoracic viscera, due to, 289 of trachea, 292 Abscess, of heart, cases reported, 202 causes, 202 outcome, 202 position, 202 varieties, 202 of lung, aetiology of, 358 bibliography of, 360 cases reported, 358 caused by polypus, 403, 404 differential diagnosis, 399 due to influenza bacilli, 366 forms of, 366 frequency of, 358 from foreign body, 341-343, 360 most frequent complication of, 366 most frequent location, 358 opening spontaneously, 360, 362 operation for, 312, 367 Abscess of lung, operated on, 358- 365, 368, 369 operated on with recovery, 358- 360, 362-365, 368 prognosis of, 366 relative frequency of pneumonia following incision for, 366 requiring excision of lung, 359 resulting in fistula, 359 simulates other conditions, 365 sputum in, 365, 366 symptoms and diagnosis, 365 to locate after incision, 367 treated by injection of carbolic, 360 treated surgically, 358-365 treated surgically with recovery, 358-360, 362-365 treatment of, 313, 366 tuberculous, operated on, 358, 359, 361-363, 365 Actinomyces, animals which are im- rnune, 235, 443 description of, 235 granule of, appearance of, 235, 442 in heart, how infected, 235 possible outcome of, 235 macroscopical diagnosis, 235 mode of infection, 235 mycelium of, 235, 442 where located in mouth, 442 Actinomycosis, bibliography of, 445 of lung, 442 appearance of, 442 cases reported, 443 cases operated on and results, .445 clinical diagnosis of, 443 mode of infection, 442 mortality of, 442 mortality of, affected by surgery, 442 symptoms of, 442 treatment of, 444 49Q 500 INDEX Actinomycosis, most frequent loca- tion of, 445 spread of, 442 pus in, 442 Adrenalin, action of, 36 in shock, 36 Agar-agar, injected into pleural cav- ity, 298 Anatomy, comparative, 10 Aneurysm, of heart, cases reported, 179, 180 causes of, 179 position of, 179 symptoms, 179 of right auricle, 124 ventricular, 121 Anthrax, aetiology of, 438 in animals, 437 bacillus of, 437 geographical distribution of, 437 in heart, 22,"] incubation period, 237, 438 in lung, cases reported, 438 mode of infection, 237 symptoms of, 438 Aorta, abnormalities of, 42-46 aneurysm of, tied off, 34 of fish, 8 rupture of, 123 Aortic arch, 11 in birds, 12 in crocodile, 11, 12 in mammals, 12 Aortic pressure, 25 Apneumatosis, see Atelectasis Arteries, abnormalities of, 8 in birds, 12 bronchial course and communica- tions, 284 distribution of, 284 origin of, 284 cardiac, peculiarity of, 17 in carp, 13 in cctacea, 12 coronary, 20 cause of rupture of, 124 ligation of, 22 differ from veins, 13 in domestic ox, 12 in dugong, 12 in echidna, 12 in fishes, 13 of heart, 20 in hedgehog, 12 in kangaroo, 13 in lemur, 12 Arteries, in lion, 12 in mammals, 12 pulmonary, expansion of, effect on bronchi, 24 abnormalities of, 42-47 distribution of, 28 transposition of, 42 respiration, efifect of, on, 25 in sloths, 12 Arterioles, relaxation of, effect of, 35 Aspergillus, 445 description of, 235 in heart, position of, 235 in lung, cases reported, 446 varieties, 235, 445 varieties described and compared, 446 Aspiration, to induce heart action, 154 of pericardium, 248 Atelectasis, acquired, causes of, 405 bibliography of, 409 cases reported, 406 complications of, 406 congenital, 405 mechanism of collapse, 405 most common cause, 408 paralysis of pneumogastric caus- ing, 408 pathology of, 408 physical examination in, 407 symptoms and diagnosis, 407 treatment of, 408 value as evidence, 405 Auricles, contraction of, 21 fibroid tumor in, 213, 214 independent action of, 22 negative pressure in, 26 rupture of, 122, 123, 125 sseptum of, formation of, 40 Bacilli, bibliography of, 243 Bacillus, aerogenes capsulatus, 438 « in appendicitis and strangula- tion, 439 bibliography of. 440 in heart of rabbits, 243 in intestine, 439 relation to emphysematous gan- grene, 439 variation in action, 439 anthracis, 437 of gangrene, 375 oedematis maligni. 438 appearance of colonies of, 236 associated with tetanus, 237 INDEX 5(ji Bacillus, ocdcmatis nialigni, in heart, 237 location of, in body, 237 source of infection, 237 where found in nature, 438 pneumonia.', Friedlaender, descrip- tion of, 440 in exudates, 440 value of, in diagnosis, 440 tuberculosis, 440 in lesion, 440 mode of infection, 440 typhosus, in heart, 243 in lung, 441 Benign tumors, treatment, 425 Bibliography of, anatomy of heart, 28 anatomy of lung, 288 abnormalities of lung, 292 abscess of heart, 204 abscess and bronchiectasis of lung, 369 actinomycosis, 445 angeioma of heart, 217 atelectasis and apneumatosis, 409 bacilli, 239 bacillus aerogenes capsulatus, 440 calcification in heart, 199 carcinoma of heart, 226 carcinoma of lung, 435 cardiac aneurysm, 181 cardiamorphia, 49 cardioclasia, 125 cardioliths, 194 cardiorrhaphy, cardiotomy, heart sutures, 175 cysticercosis, 462 cysticercus, 2^3 echinococcus, 228 echinococcus in lung, 454 ectocardia. Si experimental research on heart, 37 experimental research on lung, 298 fibroma of heart, 214 foreign bodies in lung, 350 gangrene of heart, 212 gangrene of lung, 383 gunshot lacerated and incised wounds of heart, 99 gunshot wounds of chest, 329 hernia of lung, 395 influence of trauma on lung, 298 lacerated and incised wounds of lung, 339 lipoma of heart, 216 Bibliography of, malignant tumors of lung, 428 miscellaneous, of heart, 243 myxoma of heart, 218 oedema of lung, 400 oidium albicans, 236 operations on lung, 316 paragonimus Westermani, 459 parasitic fungi of heart, 236 pneumonomycosis, 448 pneumonotomy and anaesthesia, 316 polypi of heart, 220 rhabdomyoma of heart, 218 rupture of lung, 388 sarcoma of heart, 224 sarcoma of lung, 431 syphilis of heart, 207 syphilis of lung, 417 trichina spiralis of lung, 465 tUfberculosis of heart, 239 Blood, coagulation of, 27 cause of, 27 color of, 27 endothelium in vessels, loss of, ef- fect on, 28 fibrin, 27 effect of micro-organisms on, 28 supply of, to lungs, 286 volume of, effect of diminished watery element on, 27 effect of haemorrhage on, 27 effect of food on, 27 effect of increased watery ele- ment on, 27 Blood pressure, adrenalin, effect on, 36 in heart, 25 low, effect on heart of, 35 negative, 25 opening thoracic cavity, effect on, 26 positive, 25 in veins, 26 Blood vessels, acupressure, value of, 305 ligation of, history of, 300-305 methods to stop bleeding of. 300-304 rete mirable, see Rete mirabile torsion of, value of, 305 Branchial arches, in ceratodus, 11 in frog, ri in Icpidosirens, II in sharks, il 502 INDEX Bronchial polypus, see polypus Bronchiectasis, per cent, of recover- ies after operation, 276 Bronchioles, 284 Bronchus, arteries of, see Arteries description of, 284 infundibula vesica, 283 muciparous ducts of, 284 muscular coat, function of, 284 sscptum bronchiale, position of, 283 sensibility of, 285 in sheep, 283 operations on, see Operations Bulbus arteriosus, 11 Calcification in heart, cases re- ported, 198 causes, 198 position of deposit, 198 Capillaries of lung, 295 Carcinoma, see Tumors Cardio-pneumatic movement, 24 Charcoal and coal, in lungs, effect of, 343 Chondroma, see Tumors Circulation, arterial, effect of res- piration on, 25 artificial respiration, effect of, on, in batrachian, 14 change at birth, 8 coronary, effect of, on heart, 35 in crocodiles, 15 in Crustacea, 9 in fish, 14, 15 fcetal, persistence of, 46 foramen ovale, patency of, effect on, 41 in frogs, 11 interventricular openings, effects of, on, 42 in lepidosiren, 15 in monoptcrus, 15 l)ortal, 13 renal, in batrachians, 13 in reptiles, 11 respiration, effect of, on, 295 respiratory, in mollusca and Crus- tacea, 9 time required for, 10 vasomotor collapse, effect on, 35 in vertebrates, 14 Concretions in heart, cases reported, 192 as foreign bodies, 192 fibrous, 192, 193 Concretions in heart, origin of, 192 varieties, 192 Conus arteriosus, atresia of, 46 stenosis of, 45 Coronary arteries, abnormal, num- ber of, 42 obstruction of, effect of, 48 Crustacea, circulation in, 9 Cyanosis, 42, 43 Cysticercosis of lung, 460 bibliography of, 462 symptoms, diagnosis, and treat- ment of, 461 Cysticercus, in animals, 460 bibliography, 233 description of, 460 in heart, cases reported, 233 frequency of, 233 in lung, 460 in man, most frequent location, 231 in meat, appearance of, 461 mode of infection of lung, 461 organs invaded by, 460 sources of infection, 232, 460 taenia saginata, description of, 231 in beef, 22,2 taenia solium, description of, 232 in urine, 461, 462 Dermoids, see Tumors Dextrocardia, 47, 48, 77-79 Diaphragm, abnormalities of, see Abnormalities in amphibia and lower animals, 297 in fish, 249 in mammals, 297 Displacements, of heart, 78 acquired, 79, 80 causes of, yj, 79, 80 congenital, 77 hernia of, 80 symptoms of, 78 transposition of, 77 Ductus arteriosus, 12 abnormalities of, 42-47 in cryptobranchus, 12 Ductus Cuvieri, in fish, 14 Dugong. heart of, 8 Dyspnoea, effect of, on heart, 25 EcHiNococcus, 227 cXtiology, 227, 449 appearance in meat. 227 bibliography of, 228 bibliography of, in lung, 454 cyst of, outcome of, 449 INDEX 503 Echinococcus, disease in man, caused by, 449 fluid in cyst, composition of, 449 geographical distribution of, 449 location of, 449 operation for, 454 to prevent infection, 454 in vein, effect of, 449 in heart, cases reported, 227 form and position, 227 frequency of, 227 mode of infection, 227 possible outcome, 227 in lung, cases reported, 450 cyst incised, 450 diagnosis of, ^3 frequency of, 449 mortality aflfected by operation, 450 mortality when treated by punc- ture, 450, 451 operated on, with recovery, 450, 451 symptoms, 453 treatment of, 453 variety of cyst in, 450 Ectocardia, cases reported, 77 Ectopia cordis, 77 Electricity, to induce heart action, 153 Emphysema, in wounds of lung, 335 Endocardium, description of, 16 Entozoa, in heart, cases reported, 228 Experimental research, heart action, induced, 261 analysis of tables relative to ex- periments on dog, 496 deductions from, 474 on heart of dog, caution against much manipulation of heart, 253 efifect on heart of contraction of lung, 253 ligation of coronary artery, re- sult of, 259 needle puncture, result of, 261 operative technique in, 250 rapidity of coagulation of blood, 252 record of experiments, 262 remarks on experiments, 258 suturing heart, 255-257 treatment of haemorrhage in, 251 on lungs of dog, conclusions re- garding, 472 record of experiments, 487-495 Experimental research, tabulated re- port, 497, 498 vessels injected, 472 relations, lungs and heart of dog, 471 Fixation of chest, value of, in wounds of lung, 339 Foramen ovale, at birth, 8 formation of, 40 patency of, 40-44, 46-48 cyanosis in, 42 cause of, 40 Foreign bodies, in heart, 95, 97, 98, 189 cases reported, 189 concretion, 192 effect on life, 189 most frequent position, 189 variety of articles found, 189, 190 in lung, abscess resulting from, .341-343 bibliography of, 350 calcareous bodies, size, form, color, and composition, 342 cases reported, 341 frequency on left side, cause of, 349 gangrene resulting from, 342 laryngotomy for, 345. 346 opinions as to operation for, 345 paths of escape of, 341 physical signs of, 347 position, change of, in expan- sion and contraction, 341 records of miscellaneous cases, 344 short record of 1,000 cases, 344 simulating tuberculosis, 344 symptoms of, 346 tabulated cases referring to treat- ment, 344-346 tracheotomy for, 343-346 treatment for, 348 variety of articles found, 241-244 in pericardium, 93 Fossa ovalis, 10 in kangaroo, il Frog, heart of, 11 Gall bladder, obliteration of, 77 Ganglia, cardiac, 19 efifect of injury to, 19 inferior cervical, 17 intra-cardiac, 20 efifect of opium on, 20 504 INDEX Gall bladder, effect of stimulation on, 23 formation of, 20 position of, 20 in lungs, 287 automatic pulmonary, 297 middle cervical, 17 peripheral, 297 superior cervical, 17, 18 sympathetic, 17 Wrisberg's, 18 Gangrene, of heart, 212 cases reported, 212 of lung, aetiology of, 375 bacillus of, 375 bibliography of, 382 cases reported, 376 differential diagnosis, 399 forms of, 375 mortality of, 376, 377 most frequent location, 367, 375 operated on, 376-380, 382 operated on, with recovery, 376, 377-3^2 operation for, 381 pathology of, 380 recoveries, per cent, of, after op- eration, 276 symptoms and diagnosis of, 380 treated with creosote, 380 treatment, 313 various causes of, 342, 376, 403 H^MOPERiCARDiUM, Symptoms of, 334 . Haemoptysis, polypi in bronchia, causing, 402 in wounds of lung, 334 possible causes, 335 Haemorrhage, in wounds of lung, 334 treatment of, 338 Heart, abnormalities of, see Abnor- malities abscess of, see Abscess absorption of fluid by, 249 action, 21 external pressure, effect of, on, 23 extracardiac nerve centres, ef- fect of, on, 24 relation to respiration, 24 stopped, 23 adrenalin, effect of, on, 37 in amphioxus, ri aneurysm of, see Aneurysm aspiration of, 32 Heart, aspiration, abscess cavity of, 98, 203 atrophy of, effect on size, 41 of batrachians, 11 beat, mechanics of, 20 benign tumor of, see Tumors of birds, shape of, 11 blood vessels of, 16, 17, 20 calcification, see Calcification cavities of, 9 capacity of, 10 of chelonian, shape of, 11 connective tissue of, 16 contraction of, reversed, 20 displacements of, see Displace- ments of dugong, 8, II dyspnoea, effect of, on, 25 of elasmobranchii, 11 embryonic, 7, 8 endocardium, 16 energy expended by, during nor- mal lifetime, 26 energy expended by, in 24 hours, 26 excised, rhythm of, 22 of fish, 7, 8, II foreign bodies in, see Foreign bodies. fossa ovalis of, 10 of frog, II contraction, after death in, 22 gangrene of, see Gangrene of higher vertebrates, 8 hydatids of, operation for, 146 incisions of, effect of, 22, 23 inherent force, causing contrac- tion, 21 impulse beat, where detected, 21 of invertebrates, 7 of lancelet, 11 malformations of, see Abnormali- ties mammalian, function of, 9 muscle corpuscle of, 16 muscular tissue of, 16 needle removed from, 97, 146 needle puncture between ventricles, effect of, on, 32 nerves of, 17 non-penetrating gunshot wounds, effect on, 33 operations on, cases reported, 156- 169 operation first attempted, 146, 147 position of, 9 INDEX 505 Heart, pressure, effect of, on, 249 pressure in pericardium, effect on, 32 pressure on, from pericardial fluid, 249 puncture of, 31 puncture of, effect on, 32, 33 trauma, effect of, on muscle fibres of, 33 reaction to stimuli in higher mam- mals, 23 reflex inhibition of, 24 relation to lungs, 9 in reptilia, 10 resuscitation, 153 rhythm of, when excised, 22 rhythmic contraction of, 32 in rigor mortis, 24 rupture of, see Rupture shape of, 9 stimulated by needle, 22 suture of wounds of, 33 sutures of, see Sutures suturing of, possibilities of, 32 syphilis of, see Syphilis of teleosteans, 11 terminology of, 5 of tortoise, contraction after death, 22 walls of, 10 weight of, 9 wounds of, see Wounds Heart action, to induce, see Resusci- tation Hernia, of lung, 390 acquired, some causes of, 392 bibliography of, 395 cases reported, 391 in civil war, 393 congenital, 393 diaphragmatic, 390, 393 differentiated from, 390 frequency of, 391 indication for operation for, 391 operated on, 276, 392, 393 with recovery, 276, 392, 393 " recoveries after operation, 276, 392. 393 relative frequency right and left lung, 391 respiration, effect of, on, 394 results, if not reduced, 390 symptoms and diagnosis, 394 traumatic, 393 treatment, 391-394 Hernia, usual cause, 390 Hydatid cyst, of lung, treatment, 313 Hypertrophy, of heart, muscular fibres in, 33 Hypoglossal, formed by, 19 Incision, of heart, caution in, 20 Infusion of saline to stimulate, 36 Injuries, see Wounds Interventricular sseptum, abnormali- ties of, see Abnormalities Laryngotomy, for foreign bodies, 345, 346 Ligatures and sutures, application of, in lung tissue, 480 first used, 300 history of, adhesive inflammation due to, 303 animal ligature first used in America, 302 catgut first used, 300 double ligatures first used, 300 ends first cut short, 302 filo-pressure, 305 materials used, 300-302 methods of ligating arteries of chest, 307 needle used, 301 to prevent cutting, 301 vessels ligated, 300, 301 materials compared, 303-306 non-absorbable, effect on vessels, 304 Liver, abnormalities of, with dis- placed heart, 77 Lung, atelectasis, and apneumatosis, see Atelectasis. abnormalities of, see Abnormalities alveoli of, description of, 285 bibliography of anatomy of, 288 in birds, 287 blood supply to, 286 capillary circulation of, in frog, 286 capillary circulation of, in man. 2S6 capillary circulation of, in reptilia, 286 cicatrices of, effect of, 287 collapse of, see Atelectasis description of, 282 of dog, 471 effect of pinching, 297 effect of trauma on, 298 endosmosis of gases, 296 to fix, injection of fluid into pleural cavity, 298 5o6 INDEX Lung, foreign bodies in, see Foreign bodies, 341 gangrene of, see Gangrene hernia of, see Hernia influence of trauma on, bibliogra- phy of, 298 injuries of, see Wounds lymphatics of, 285, 286 in monkeys, 283 nerves of, course of, 287 nerve plexuses of, formed by, 289 operations on, see Operations pigment in, 285 pleural covering, see Pleura respiration begins right side, 283 retraction of, efifect on haemor- rhage, 477 rhythm of, controlled by, 297 rupture of, see Rupture in snake, 287, 290 sutured, 333 syphilis of, see Syphilis terminology, 279 tumors of, see Tumors of water-dog (necturus latera- lis), 287 wounds of, see Wounds Lymphatics, of lungs, 285, 286 Lymphoma, see Tumors Malignant oedema, tissues espe- cially affected, 438 Malignant tumors, see Tumors Manipulation, heart action induced by, 153, 154 Mediastinum obliterated, 289 Mollusca, circulation of, 9 Muciparous ducts, of bronchi, 284 Mycosis, of heart, 234 cases reported, 234 position of growth, 234 Myxoma, see Tumors Needling, to stimulate heart, 154 Nerves, cardiac plexus, 17, 18 of heart, 17, 18 plexus cardiacus, 18 pneumogastric, 17, 18 pneumogastric, to heart, 17 pulmonary plexuses, formed by, 285, 286 sympathetic, to heart, 17 sympathetic, to pulmonary plexus, 285 vagus, to pulmonary plexus, 285 Nerves, vasomotor collapse, 35 vasomotor, shock, 34, 35 CEdema, definition of, 397 of lung, aetiology of, 397 bibliography of, 400 cases reported, 397 caused by hgemorrhagic infarct, .398 differential diagnosis of, 397-400 division of vagi, efifect on, 398 secondary to nephritis, 397 sputum in, 400 symptoms and diagnosis, 398 treatment of, 399 Oidium albicans, bibliography of, 236 description of, 236 in heart, 236 in lung, 448 Operations, for abscess of lung, 367 bronchotomy, 309 indications for, 309 technique of, 348 for echinococcus in lung, 454 for foreign bodies in lung, 348 for gangrene of lung, 381 on heart, experimental, for mitral stenosis, 33 for hydatids, 146 cases reported, 156-169 suturing, 33, 255-257 for ligation of bronchus, 476 laryngotomy, for foreign bodies, 345, 346 pneumocele, treated by excision, 331 pneumonectomy, 308 indications for, 308 pneumonopexy, 308 pneumonorrhaphy, 308 pneumonotomy, anaesthesia in, 314 cases reported, 310, 311 indorsed, 333 sterilization in, 314 technique of, 313-315 for tuberculosis abscess, 358, 359, 361 tracheotomy for foreign bodies, 343-346, 348 for trichina spiralis in lung, 464 on lung, 435 amount of tissue to be incor- porated in ligature, 476 anaesthesia in, 314 for aseptic lesions, mortality of, 312 INDEX 507 Operations, on !ung, bibliography of, 316 cases reported, 308, 309 closing chest not advisable in, 477 drainage in^ 476 excision, 297, 309 excision with recovery, 309 expansion, when chest wound closed, 477, 481 extirpation, 297 forceps, kind to be used in, 477 incision in, 475 for hydatid cyst, mortality of, 312 haemorrhage in, if uncontrolla- ble, treatment of, 475 methods of dividing tissue in, 311 needle to be used in, 480 removal one or more lobes, re- sults of, 479 to secure vessels in, 481 septic lesions, mortality in, 312 suture material used in, 308 sutures and ligatures in, 480-483 tearing versus cutting in, 476 technique of, 312 treatment of stumps in, 481 Osteoma, see Tumors Paragonimus Westermani, aetiology of, 457 in animals, 457 in brain, 457 cases reported, 457 frequency of, in Japan and For- mosa, 457 geographical distribution of, 457 introduced into this country, 458 location in man, 234 in lung, 457 bibliography of, 459 extension of infection, 458 mode of infection, 234 sputum in, 458 symptoms and diagnosis of, 458 treatment of, 459 and tuberculosis, 234, 457 Pericardium, abnormalities of, 289 absorption of fluid by, 249 aspiration of, 248 description of, 15 in elasmobranchii, II fibrous layer of, 15 in fish, 249 Pericardium, historical surgery of, 152 in myxinoid fishes, 11 relation to heart and vessels, 9 serous layer, 15 shape of, 9 sutured, 96 opened, 34 Peritonaeum, in elasmobranchii, 1 1 in myxinoid fishes, 11 Pigment, in lungs, 285 Plates, description of, I and LVll- LXIII, 484 Plexus cardiacus, ganglia of, impor- tance in, 18 formation of, 18 position of, 18 Pleura, description of, 282 effusion in, caused by gunshot wound, 324 in lower animals, 282 lymph stream of, 282 Pneumocele, see Hernia of lung Pneumogastric, 18 branch to dura mater, 19 communication with other nerves, 19 Pneumonectomy, see Operations Pneumoniae, bacillus of, 440 foreign body causing, 343 Pneumonomyces, 447 Pneumonomycosis, bibliography of, 448 cases reported, in lungs, 447 lesions, symptoms, and diagnosis, 447 Pneumonopexy, see Operations Pneumonorrhaphy, see Operations Pneumonotomy, see Operations Pressure, to induce heart action, 153, 154 Pulmonary artery, in crocodilia, 11 for other references, see Arteries Puncture, relative haemorrhage, au- ricle and ventricle, 33 Reptilia, heart of, 10 Respiration, effect of trauma to chest on, 298 Resuscitation, methods of, 153 Rete mirabile, in cetacea, 12 in domestic ox, 12 in lepidosiren, 13 in osseous fishes, 13 in porbeagle shark, 13 venous, in porpoise, 13 5o8 INDEX Rhabdomyoma, see Tumors Rupture, of aorta, 123, 124 of coronary arteries, 124 of heart, 124, 125 cases reported, 120 causes of, 120 fatty degeneration as factor in, 120, 121 formation of clots in, 120 position most frequent, 120 spontaneous, 120-122 varieties of, 120 from violence, 123 with recovery, 121 interventricular sa;ptum, 123-125 of lung, 290, 386 associated with fracture of ribs, 388 bibliography of, 388 cases reported, 387 variety of causes, 387, 388 without injury to chest, 386 of pericardium, 121 Saline solution, to induce heart ac- tion, 153 infusion of, action of, 36 Sarcoma, see Tumors Septic lesions, of lungs, per cent, re- coveries after operation, 277 Shock, adrenalin in, 36 saline infusion, efTect in, 36 stimulants in, action of, 36 surgical, 34 treatment of, 36, 37 vasomotor nerves in, 34 vicious circle in, 35 Sinus venosus, 11 in batrachians, 14 in fish, 14 in reptiles, 14 Suture, of heart, accidents that have occurred during, 171 ana;sthesia in, 171 analysis of cases reported, 170- 173 entrance for, 171 cases reported of. 156-159 causes of death in, 172 Suturing of heart, caution in, 20 material used, 172 mortality in, 172 prognosis best, what age, 172, 173. resulting in recovery, 157-160, 162, 163, 166 Suturing of heart, time of operation after injury, 171 Syphilis, heart, 206 associated conditions, 206 cases reported, 207 character of gummata, 207 forms of, 207 myocarditis, due to, 206 prognosis, 206 time after initial lesion, 206 valvular lesions, due to, 206 of lung, 411 abscess, caused by, 411 bibliography of, 417 cases reported, 411 differential diagnosis of, 399 gangrene, caused by, 411 Systole, force of, 26 Temperature, extremes of, to in- duce heart action, 153 Terminology, of heart, 5 of lung, 279 Thoracic duct, injury to, 336 Tracheotomy, see Operations Transfusion, amount of blood that may be safely used, 27 Trichina spiralis, 233 cyst of, description of, 464 in heart, 233, 234 location in man, 464 of lung, bibliography of, 465 operation for, 464 treatment of, 464 mode of infection, 234 Tuberculosis, in heart, bibliography of, 239 cases reported, 238 forms of, 237 where located, 238 of lungs, per cent, of recoveries af- ter operation, 277 Tumors, angcioma, of heart, 216 bibliography of, 217 cases reported of, 217 course of, 216 position of, 216 benign, of heart, 213 benign, of lung, cases reported, 422 carcinoma, of heart, 224 bibliography of, 226 cases reported, 225 location and varieties, 224 carcinoma of lung, 432 bibliography of, 435 INDEX 509 Tumors, carcinoma of lung, cases re- ported, 432 pathology of, 434 prognosis of, 434 rapidity of growth, 432 treatment of, 435 chondroma, of lungs, 423 treatment of, 425 dermoids, of lung, 424 treatment of, 425 division of, 422 fibroma, of heart, 213 bibliography of, 214 cases reported, 213 lipoma, of heart, 215 age and sex, 215 bibliography of, 216 cases reported of, 216 varieties of, 215 lymphoma, of lung, 422 pathology of, 423 treatment of, 425 malignant, of lung, 426 bibliography of, 428 cases reported of, 426 myxoma, of heart, bibliography of, 218 cases reported, 218 description of, 218 osteoma, of lung, 423 causes of, 424 influence of heredity, 424 removal of, indications for, 424 structure of, 423 treatment of, 425 varieties of, 423 polypi, in bronchus, 402 cases reported, 403 efifect of, 402, 403 frequency of, 402 possible outcome of, 402 symptoms of, 403 polypi of heart, bibliography of, 220 cases reported, 219, 220 description of, 218 position, 219 polypi of lung, 403 rhabdomyoma, 217 position of, 217 sarcoma of heart, bibliography of, 224 c-ases reported, 223 description of, 223 outcome of, 223 varieties of, 223 Tumors, sarcoma of lung, bibliog- raphy of, 431 cases reported, 430 frequency of, 429 haemorrhage in, 430 pathology of, 430 Valves, abnormalities of, 78 Vasomotor centres, circulation to, effect when interfered with, 35 infusion, effect of, on, 36 Veins, anomalies of, 8 in batrachians, 13 in birds, 14 blood pressure in, 26 effect of changed position on, 27 bronchial, termination, 284 in cetacea, 13, 14 contractile, 14 differ from arteries, 13 in eel, 14 in heart, 17, 20 in monotremes, 13 negative pressure in, 26 in porpoise, 13 pulmonary, 44 course, in lungs, 286 origin, 286 receive venous radicles from lung, 284 in rabbits, 13 in Thyxine, 14 vena azygos, ligation of, in opera- tions, 285 receive branches from lung, 284 vena cava, abnormalities of, 42, 46 in birds, 8 in lower mammals, 8 vena porta, analogous to, 8 Venesection, in treatment wounds of lungs, 336 Venous system, of fish, compared with embryo, 14 Ventricles, atresia of, 46 contraction of, 21 fibroid tumors of, 213 independent action of, 22 negative pressure in, 25, 26 relative force of, 10 relative thickness of, 10 relative work of right and left, 26 rupture of, cause of, 96 rupture of right, 120-123, 125 rupture of left, 120, 121, 125 total work of, 26 5IO INDEX Ventricles, wounds of, relative mor- tality, right and left, 146 Vertebral artery, in llama, 12 Vessels, effect on, of adrenalin, 37 transposition of, 44 transposition of aorta and pul- monary artery, 45, 47 Viscera, transposition of, 44 Wounds, of aorta, 94, 95 of auricles, 91-96 of bronchus, treatment of, 478 of chest, gunshot, 322-329 of coronary artery, 95 gunshot, bibliography of, 329 comparative study of, in civil and Spanish-American wars, 326 table of, during civil war, 327 tables showing mortality in war, treated by digitalis, in war, 325 treated by venesection, in war, 325 of diaphragm, 323 of heart, 91-96, 98, 125 cases reported, 91 causes of death in, 146, 155 complication in, 146 conclusions regarding surgical treatment of, 163, 165 extra pericardial, 92, 146 factors of importance in, 148 mortality from, 146 most often caused by, 91 recovery from, 92, 94, 96, 97 reports of, in civil war, 93 surgical treatment of, 151 symptoms of, 148-150 tables concerning, 97, 98 treatment of, 150 of liver, 95 Wounds, of lung, best mode of oper- ating, 475 bullet, aseptic, 322, 328 cases reported, 322 cause most frequent, 322 causes of death, 336 with complications, 332-334 chest hermetically closed, result of, 325 effects of, 297 with emphysema, 331 fever in, 335, 336 fixation of chest, value of, in, 337 with formation ossiform concre- tions, 331 haemorrhage in, 334 lacerated and incised, 330 bibliography of, 339 cases reported, 330 laceration of, without fracture of ribs, 331 prognosis of, 336 recoveries from, 330-333 recovery after gunshot, some cases reported, 322-324 reports chest wounds, civil war, 326 resulting in fistula, 324 symptoms of, 334 symptoms of lung bleeding in, 334 treated by thoracentesis, 331 treatment of, 336, 480 treatment of, essentials of, 480 venesection in treatment of, 336 paracentesis, with injury of heart and recovery, 96 of pericardium only, 93-95 pleural effusion, caused by, 324 of thoracic duct, 336 of vena cava, 95 of ventricles, 91-96, 98, 125 COLUMBIA UNIVERSITY LIBRARY This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE C2ei23S)MI00 ^1 "li uS I 111 RD536 j^42 Ricketts The surgery of the heart and lungs RD^°5^^g^j^^4U^IWRSITY LIBRARIES (hsLstx) '^^^ ^^,l.9,^%9.Uhe heart and lungs, 2002245400 vKvW /Is.v.w.ViS