Commentaries on the Surgery of the War in Portugal, Spain, France, and the Netherlands / from the battle of Roliça, in 1808, to that of Waterloo, in 1815; with additions relating to those in the Crimea in 1854-55, showing the improvements made during and since that period in the great art and science of surgery on all the subjects to which they relate.

by G. J. Guthrie

When a murmur or sound is heard of a different kind, possessing the character of friction, of surfaces moving backward and forward on each other, or to and fro, it is the sign of inflammation of the membrane covering the heart, as well as of that lining the fibrous external tissue of the pericardium. The signs of both external and internal inflammation may be present at the same time, and they frequently are in cases of acute rheumatism.

357. When the heart is supposed to be wounded, even without much loss of blood, there is fainting; palpitation; irregular movement or total cessation of its action; coldness of the extremities; ghastliness of countenance, succeeded by great anxiety; a sense of anguish; an intermission or cessation of pulse, followed, if the patient should survive, by reaction, which renders it very frequent and sometimes increases its impulse; while the anxiety is increased by pain, sometimes intolerable, referred to the part. These symptoms imply a serious injury, although they may not all be present, and many of them differ in intensity. If the patient should survive, the ordinary sounds of the heart will return, with more or less irregularity, accompanied after a few hours by the endocardial murmur, although something like it may perhaps be observed from the first period of injury. The friction or attrition sound, indicating the presence of inflammation of the pericardium, may be absent; it will not be discernible, if a layer of blood be effused into the cavity of that membrane; while the natural sounds of the heart are rendered more indistinct as the heart is separated from the walls of the chest by the effusion which distends the pericardium, and impedes the regular action of the heart, but cannot compress it, as an empyema does the lung. If inflammation take place without an effusion of blood, the friction sound will be heard, and will usually continue even after some effusion of serum and of lymph has occurred, as the quantity of serum secreted is rarely sufficient to prevent the effused and attached portions of lymph from rolling against each other.

The presence of a larger quantity of fluid may be more distinctly known by percussion, if it can be borne in cases of injury, the degree and extent of the dullness being the measure of its existence and accumulation. It may extend over a part or over the whole of the precordial region, reaching as high as the second, or even the first rib, beneath the sternum, and even under the cartilages of the ribs of the right side.

358. That the heart when wounded is capable of recovery by the permanent closure of the wound, in a few rare instances, is indisputable; and it would seem, from a consideration of the different cases which have been recorded, that such recovery takes place in consequence of there being but little blood discharged through the wound, or into the cavity of the pericardium, or into that of the pleura. The absence or the cessation of the hemorrhage by the contraction of the wound, or the formation of a coagulum, is the first step toward a cure, and it was to one or other of these circumstances that most of those who survived the injury for several days or weeks owed their existence for the time, although they usually died from the effects of inflammation, more of the inner lining and outer covering than of the substance of the heart itself.

If the wound be inflicted by a musket or pistol-ball, it cannot be closed, although pressure may be made upon it for a time, so as to suppress the external flow of blood. If this should succeed, it is more than probable that the hemorrhage will continue internally, and that the patient may die after much suffering, principally from oppression, caused by the escape of blood into the cavity of the chest.

If the wound be a stab, the external opening may be accurately closed, and the escape of blood prevented; but as the pressure of the blood in the pericardium is unequal to restrain the action of the heart, blood forced out through the opening fills the cavity of the pleura, and causes suffocation, unless from some accidental circumstance the opening in the heart becomes obstructed, and the bleeding ceases.

If all the circumstances be considered, there can be no doubt of the propriety of closing the wound in the first instance, if the flow of blood be excessive and appear likely to endanger life. It seems to be as little doubtful that the wound should be reopened after a time, if the danger from suffocation be imminent. The relief obtained by the escape of a little blood may be efficacious, while it does not necessarily follow, although it is more than probable it will be so, that its place will be occupied by a further extravasation of blood, which will prove fatal. It is a choice of difficulties, and death from hemorrhage is easier than death from suffocation.

In the case of the Duc de Berri, whose right ventricle was wounded, and who died from loss of blood, Steifensand reprehends Dupuytren for having opened the external wound every two hours, to prevent suffocation; but if death were actually impending from the filling of the cavity of the chest being about to cause suffocation, there was nothing to be done but to give relief at all hazards.

359. When the sufferer has recovered from the imminent danger attendant on the infliction of the injury, and the pericardium is believed to be so full of blood or of serum as to prevent in a great measure the movements of the heart, it has been proposed by Baron Larrey to open the pericardium by the following operation—equally, as he thinks, applicable in an ordinary case of hydrops pericardii:—

“An oblique incision is to be made from over the edge of the ensiform cartilage, to the united extremities of the cartilages of the seventh and eighth ribs. The cellular tissue being divided with some fibers of the rectus and external oblique muscles, there remains only a portion of the peritoneum called its false layer, above the pericardium, which can be seen after the division of all the intervening cellular tissue, projecting between the first and second digitations of the diaphragm. Into this the bistoury is to be entered, with the precaution of doing it with the edge turned upward, and directed a little from right to left, to avoid the peritoneum. The smallest portion possible of the anterior border of the diaphragm is next to be divided, where it is attached to the inner part of the cartilage of the seventh rib. The internal mammary artery is to the outside. The patient should be placed perpendicularly, and supported on his bed, which inclines the anterior part and base of the pericardium to the fore part of the chest.”