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

Lacerations and ruptures of the heart have frequently taken place from blows or other serious contusions.

Ollivier, who devoted much time to reading and collecting the observations made by different writers on the injuries of the heart, says: “That of forty-nine cases of spontaneous rupture of the heart, thirty-four were of the left ventricle, eight only of the right, two of the left auricle, three of the right, and that in two cases both ventricles were torn in several places; and that these results were in an inverse proportion to those which occurred after blows or contusions; the right ventricle being ruptured in eight out of eleven cases, the left ventricle three times; the auricles being also torn in six of these eleven cases; the ruptures not being confined to one spot, but taking place occasionally in several different parts, or even in the same ventricle.” In eight of these cases he had noticed, the heart was ruptured in several places. That a spontaneous rupture may be cured as well as a wound, seems likely, from a case reported by Rostan, of a woman who died after fourteen years’ suffering with pain about the heart, and was found to have the ventricle ruptured. A cicatrix was observed to the left side of the recent rupture, half an inch in extent in every direction, in which the new matter was evidently different from the natural structure of the heart.

LECTURE XXVI.

WOUNDS OF THE INTERNAL MAMMARY ARTERY, ETC.

362. Wounds of the internal mammary and intercostal arteries have so much occupied the attention of theoretical surgeons, and so many inventions have been broached for the suppression of hemorrhage, particularly from the latter, that it becomes consolatory to know that bleeding from these vessels rarely takes place; that the inventions are more numerous than the case requiring them, and that no notice need be taken of them, they being as unnecessary as they are useless. I have never had occasion to see a distinct case of hemorrhage from an internal mammary artery, but if bleeding should take place from a wound in its neighborhood, of a nature to lead to the belief that it came from this vessel, the wound should be enlarged until the part whence the blood flows can be ascertained, when, if it be from that artery, the vessel should be twisted or secured by ligatures, and if these methods should be impracticable, the wound should be closed and the result awaited.

The following method of operating for the application of a ligature on this vessel has been proposed by M. Goyraud. It may be done with ease in the three first intercostal spaces, it offers some difficulties in the fourth, is very difficult in the fifth, and is scarcely to be done lower down. An incision two inches in length is to be made near the side of the sternum from without inward, at an angle of forty-five degrees with the axis of the body. The middle of this incision should be three or four lines distant (a quarter of an inch) from the bone, and in the center of the intercostal space, within which the vessel is to be found. The skin, cellular substance, and the great pectoral muscle having been divided, the aponeurosis of the external intercostal muscle with the muscular fibers of the inner intercostal muscle are to be separated and torn through with a director, until the artery and its two venæ comites are laid bare at the distance of three lines from the edge of the sternum, lying before the fibers of the triangularis sterni muscle, which separates these vessels from the pleura. A bent probe, or other proper instrument, can then be readily passed under the artery. The vessel can only be secured in this way when injured at the upper part of the chest; below this it must bleed into the cavity, unless there be an open wound.

363. The intercostal artery, although often injured, rarely gives rise to hemorrhage so as to require a special operation for its suppression; but whenever it does so happen, the wound should be enlarged so as to show the bleeding orifice, which should be secured by one ligature if distinctly open, and by two if the vessel should only be partially divided. The vessel is sometimes so small as to be easily twisted, or its end sufficiently bruised as well as twisted, to arrest the hemorrhage. It lies between the two layers of intercostal muscles, and in the middle of the ribs it runs in a groove in the under part of each.

I have had occasion to twist and bruise the end of an artery bleeding in an intercostal space, and I have tied the vessel under the edge of the rib; but I have not met with any of the great difficulties usually said to be experienced in suppressing a hemorrhage from this artery, when the wound was recent, and the parts were sound; no reliance should be placed on the hypotheses often entertained on this subject.

When the parts are unsound, and the hemorrhage is secondary, greater difficulty is sometimes experienced in arresting it, because the ligature easily cuts its way through the softened parts, and styptics are liable to fall into the cavity of the chest.

The late General Sir G. Walker, G.C.B., after scaling the wall of Badajos, with the fifth division, was wounded by a musket-ball, which struck the cartilages of the lower ribs of the right side, broke the bones, penetrated the chest, and then passed outward. He remained in Badajos under my care during the first three weeks, with many of the other principal officers who were wounded; and overcame the first inflammatory symptoms in a satisfactory manner. After I left him the wound sloughed, some part of the cartilages separated, and one of the intercostal arteries bled, although the bleeding was arrested once by ligature, and afterward, on its return, by different contrivances; each time it reappeared his life was placed in considerable jeopardy from it and the discharge from the cavity of the chest, which was profuse. The bleeding was ultimately arrested by the oil of turpentine, applied on a dossil of lint, and pressed on the bleeding spot by the fingers of assistants until the hemorrhage ceased. He recovered after a very tedious treatment, with a considerable flattening of the chest, and a deep hollow at the lower part of the side, whence portions of the rib, and of the cartilages had been removed.