Extended tolerance of foreign bodies loose in the thoracic cavity has been noticed. Tulpins mentions a person who had a sponge shut up in his thoracic cavity for six weeks; it was then voided by the mouth, and the man recovered. Fabricius Hildanus relates a similar instance in which a sponge-tent was expelled by coughing. Arnot reports a case in which a piece of iron was found in a cyst in the thorax, where it had remained for fourteen years. Leach gives a case in which a bullet was impacted in the chest for forty-two years. Snyder speaks of a fragment of knife-blade which was lodged in the chest twelve years and finally coughed up.
Foreign Bodies in the Bronchi.—Walnut kernels, coins, seeds, beans, corks, and even sponges have been removed from the bronchi. In the presence of Sir Morrell Mackenzie, Johnston of Baltimore removed a toy locomotive from the subglottic cavity by tracheotomy and thyreotomy. The child had gone to sleep with the toy in his mouth and had subsequently swallowed it. Eldredge presented a hopeless consumptive, who as a child of five had swallowed an umbrella ferrule while whistling through it, and who expelled it in a fit of coughing twenty-three years after. Eve of Nashville mentions a boy who placed a fourpenny nail in a spool to make a whistle, and, by a violent inspiration, drew the nail deep into the left bronchus. It was removed by tracheotomy. Liston removed a large piece of bone from the right bronchus of a woman, and Houston tells of a case in which a molar tooth was lodged in a bronchus causing death on the eleventh day. Warren mentions spontaneous expulsion of a horse-shoe nail from the bronchus of a boy of two and one-half years. From Dublin, in 1844, Houston reports the case of a girl of sixteen who inhaled the wooden peg of a small fiddle and in a fit of coughing three months afterward expelled it from the lungs. In 1849 Solly communicated the case of a man who inhaled a pebble placed on his tongue to relieve thirst. On removal this pebble weighed 144 grains. Watson of Murfreesboro removed a portion of an umbrella rib from a trachea, but as he failed to locate or remove the ferrule, the case terminated fatally. Brigham mentions a child of five who was seized with a fit of coughing while she had a small brass nail in her mouth; pulmonary phthisis ensued, and in one year she died. At the postmortem examination the nail was found near the bifurcation of the right bronchus, and, although colored black, was not corroded.
Marcacci reported an observation of the removal of a bean from the bronchus of a child of three and a half years. The child swallowed the bean while playing, immediately cried, and became hoarse. No one having noticed the accident, a diagnosis of croup was made and four leeches were applied to the neck. The dyspnea augmented during the night, and there was a whistling sound with each respiratory movement. On the next day the medical attendants suggested the possibility of a foreign body in the larynx. Tracheotomy was performed but the dyspnea continued, showing that the foreign body was lodged below the incision. The blood of one of the cut vessels entered the trachea and caused an extra paroxysm of dyspnea, but the clots of blood were removed by curved forceps. Marcacci fils practised suction, and placed the child on its head, but in vain. A feather was then introduced in the wound with the hope that it would clean the trachea and provoke respiration; when the feather was withdrawn the bean followed. The child was much asphyxiated, however, and five or six minutes elapsed before the first deep inspiration. The wound was closed, the child recovered its voice, and was well four days afterward. Annandale saw a little patient who had swallowed a bead of glass, which had lodged in the bronchus. He introduced the handle of a scalpel into the trachea, producing sufficient irritation to provoke a brusque expiration, and at the second attempt the foreign body was expelled. Hulke records the case of a woman, the victim of a peculiar accident happening during the performance of tracheotomy, for an affection of the larynx. The internal canule of the tracheotomy-tube fell into the right bronchus, but was removed by an ingenious instrument extemporaneously devised from silver wire. A few years ago in this country there was much public excitement and newspaper discussion over the daily reports which came from the bedside of a gentleman who had swallowed a cork, and which had become lodged in a bronchus. Tracheotomy was performed and a special corkscrew devised to extract it, but unfortunately the patient died of slow asphyxiation and exhaustion. Herrick mentions the case of a boy of fourteen months who swallowed a shawl-pin two inches long, which remained in the lungs four years, during which time there was a constant dry and spasmodic cough, and corresponding depression and emaciation. When it was ultimately coughed up it appeared in one large piece and several smaller ones, and was so corroded as to be very brittle. After dislodgment of the pin there was subsidence of the cough and rapid recovery.
Lapeyre mentions an elderly gentleman who received a sudden slap on the back while smoking a cigarette, causing him to start and take a very deep inspiration. The cigarette was drawn into the right bronchus, where it remained for two months without causing symptoms or revealing its presence. It then set up a circumscribed pneumonia and cardiac dropsy which continued two months longer, at which time, during a violent fit of coughing, the cigarette was expelled enveloped in a waxy, mucus-like matter. Louis relates the case of a man who carried a louis-d'or in his lung for six and a half years.
There is a case on record of a man who received a gunshot wound, the ball entering behind the left clavicle and passing downward and across to the right clavicle. Sometime afterward this patient expectorated two pieces of bone and a piece of gum blanket in which he was enveloped at the time of the injury. Carpenter describes a case of fatal pleuritis, apparently due to the presence of four artificial teeth which had been swallowed thirteen years before.
Cardiac Injuries.—For ages it has been the common opinion relative to injuries of the heart that they are necessarily fatal and that, as a rule, death immediately follows their reception. Notwithstanding this current belief a careful examination of the literature of medicine presents an astounding number of cases in which the heart has been positively wounded, and the patients have lived days, months, and even recovered; postmortem examination, by revealing the presence of cicatrices in the heart, confirming the original diagnosis. This question is one of great interest as, in recent years, there has been constant agitation of the possibility of surgical procedures in cardiac as well as cerebral injuries. Del Vecchio has reported a series of experiments on dogs with the conclusion that in case of wounds in human beings suture of the heart is a possible operation. In this connection he proposes the following operative procedure: Two longitudinal incisions to be made from the lower border of the 3d rib to the upper border of the 7th rib, one running along the inner margin of the sternum, the other about ten mm. inside the nipple-line. These incisions are joined by a horizontal cut made in the fourth intercostal space. The 4th, 5th, and 6th ribs and cartilages are divided and the outer cutaneous flaps turned up; pushing aside the pleura with the finger, expose the pericardium and incise it longitudinally; suture the heart-wound by interrupted sutures. Del Vecchio adds that Fischer has collected records of 376 cases of wounds of the heart with a mortality two to three minutes after the injury of 20 per cent. Death may occur from a few seconds to nine months after the accident. Keen and Da Costa quote Del Vecchio, and, in comment on his observations, remark that death in cases of wound of the heart is due to pressure of effused blood in the pericardial sac, and, because this pressure is itself a cheek to further hemorrhage, there seems, as far as hemorrhage is concerned, to be rather a question whether operative interference may not be itself more harmful than beneficial. It might be added that the shock to the cardiac action might be sufficient to check it, and at present we would have no sure means of starting pulsation if once stopped. In heart-injuries, paracentesis, followed, if necessary, by incision of the pericardium, is advised by some surgeons.
Realizing the fatality of injuries of the heart, in consequence of which almost any chance by operation should be quickly seized by surgeons rather than trust the lives of patients to the infinitesimal chance of recovery, it would seem that the profession should carefully consider and discuss the feasibility of any procedure in this direction, no matter how hypothetic.
Hall states that his experience in the study of cardiac wounds, chiefly on game-animals, would lead him to the conclusion that transverse wounds the lower portions of the heart, giving rise to punctures rather than extensive lacerations, do not commonly cause cessation of life for a time varying from some considerable fraction of a minute to many minutes or even hours, and especially if the puncture be valvular in character, so as to prevent the loss of much blood. However, if the wound involve the base of the organ, with extensive laceration of the surrounding parts, death is practically instantaneous. It would seem that injury to the muscular walls of the heart is much less efficient in the production of immediate death than destruction of the cardiac nervous mechanism, serious irritation of the latter producing almost instantaneous death from shock. In addition, Hall cites several of the instances on which he based his conclusions. He mentions two wild geese which flew respectively 1/4 and 3/4 of a mile after having been shot through the heart, each with a pellet of BB shot, the base in each instance being uninjured; in several instances antelope and deer ran several rods after being shot with a rifle ball in a similar manner; on the other hand, death was practically instantaneous in several of these animals in which the base of the heart was extensively lacerated. Again, death may result instantaneously from wounds of the precordial region, or according to Erichsen, if held directly over the heart, from the discharge of a pistol containing powder alone, a result occasionally seen after a blow on the precordial region. It is well, however, to state that in times of excitement, one may receive an injury which will shortly prove fatal, and yet not be aware of the fact for some time, perhaps even for several minutes. It would appear that the nervous system is so highly tuned at such times, that it does not respond to reflex irritations as readily as in the absence of excitement.
Instances of Survival after Cardiac Injuries.—We briefly cite the principal interesting instances of cardiac injuries in which death has been delayed for some time, or from which the patient ultimately recovered.
Pare relates the case of a soldier who received a blow from a halberd, penetrating the left ventricle, and who walked to the surgeon's tent to have his wound dressed and then to his own tent 260 yards away. Diemerbroeck mentions two instances of long survival after cardiac injuries, in one of which the patient ran 60 paces after receiving the wound, had complete composure of mind, and survived nine days. There is an instance in which a man ran 400 paces after penetration of the left ventricle, and lived for five hours. Morand gives an instance of survival for five days after wound of the right ventricle. Saucerotte speaks of survival for three days after injury to the heart.