Skielderup recommends this operation to be done by first trepanning the sternum a little below the spot where the cartilage of the fifth rib is united to that bone, at which part the periosteum lining it offers considerable resistance, and should not be divided by the trephine. Below this there is a triangular space formed by the separation of the layers of the mediastinum, free from cellular tissue, and tending a little more to the left than to the right. The apex of this triangle is opposite the fifth rib; its base touches the diaphragm. The bone having been removed, the patient is made to lean forward, when the projection of the pericardium will enable the operator to feel that a quantity of fluid is within, and to open it with safety.
360. J. Dierking, a stout, muscular man of the 3d Regiment of German Hussars, was wounded at the battle of Waterloo by a lance, which penetrated the chest between the fifth and sixth ribs, and was then withdrawn. He fell from his horse, lost a good deal of blood by the mouth, and some by the wound, and was carried to Brussels without any particular attention being drawn to the injury. His strength not being restored, while he suffered from palpitations of the heart, and other uneasy sensations in the chest, he was sent to England to be invalided; and in November, 1815, was admitted into the York Hospital, Chelsea, in consequence of an attack of pneumonia, of which he died in two days, without attention being particularly drawn to the cicatrix of the wound.
On examining the body, I found that the lance, having injured the edge of the cartilage of the rib, passed through the inferior lobe of the left lung, the track being marked by a depressed, narrow cicatrix. It then perforated the pericardium under the heart, and sliced a piece of the outer edge of the right ventricle, which, being attached below, turned over and hung down from the heart to the extent of two inches, when in the fresh state, the part of the ventricle from which it had been sliced being puckered and covered by a serous membrane like the heart itself. The lance then penetrated the central tendon of the diaphragm, making an oval opening, easily admitting the finger, the edges being smooth and well defined. It then entered the liver, on the surface of which there was a small, irregular mark or cicatrix. The heart in front was attached to the pericardium by some strong bands, the result of adhesive inflammation, but the general appearance of the serous membrane showed that this had not been either great or extensive. The pericardium was not thickened.
If this man had lived long enough, he might have furnished an instance of hernia of the stomach or of intestine into the pericardium. The preparation is in the military museum at Chatham, Class 1, Div. 1, Sect. 7, No. 156.
a, right ventricle;
b, left ditto;
c, right auricle;
d, left ditto;
e, aorta;
f, pulmonary artery;
g, coronary ditto;
h, a portion of the cartilages of the ribs seen on the inside;
i, a portion of the diaphragm;
k, the pericardium.
1, a portion of the pericardium reflected to show abnormal adhesions to the surface of the heart;
2, aperture of wound through the diaphragm and the pericardium;
3, pendulous slice off the substance of the right ventricle;
4, puckered cicatrix of the wound of the ventricle.
That the heart, when exposed, is insensible, or nearly so, to the touch, was known to Galen and to Harvey. Galen is said to have removed a part of the sternum and pericardium, and to have laid his finger on the heart. Harvey did the same to the son of Lord Montgomery, who was wounded in the chest. Professor J. K. Jung not only introduced needles into the hearts of animals, but also galvanized them without disadvantage, although Admiral Villeneuve is supposed to have died suddenly from running a long pin into his heart, which scarcely left the mark of its entrance.
That persons may die from the shock of a blow on the heart, need not be doubted, and that they do die when little blood is lost, is admitted. History preserves the fact that Latour d’Auvergne, Captain of the 46th demi-brigade, who had obtained the honorable title of “Premier Grenadier de France,” fell and died immediately after receiving a wound from a lance at Neustadt, in the month of July of the sixth year of the Republic; it struck the left ventricle of the heart near its apex, but did not penetrate its cavity. He was, however, sixty-eight years of age.
361. In wounds of the heart, all extraneous matters should be removed, if possible, and all inflammatory symptoms should be subdued by general bleeding, by leeches, by calomel, antimony, opium, etc. The chest should be examined daily by auscultation. If the cavity of the pleura should fill with blood, it ought to be evacuated to give a chance for life, and if the pericardium should become permanently distended by fluid, it should be evacuated.