two on the vertebra, and that on the intervertebral cartilage would argue a determination of purpose and strength of wrist which fall to the lot of few."

280. Thorax; concussion.-Wounds of the thorax may be as dangerous as the others that we have considered, because of concussion. Concussion of the chest most frequently follows a blow in the region of the sternum. It is uncertain just what the cause of the condition is. There are no evidences of injury to any of the organs, and yet there follows a temporary condition of weak, rapid pulse, with the symptoms of collapse, which may rarely deepen into death, but more often is rapidly recovered from. In the cases where death follows a traumatism to the chest there are usually, however, some definite lesions in some part of the body to account for the fatal outcome.

281. Nonpenetrating wounds of thorax.- Nonpenetrating wounds of the chest are not dangerous except in the cases of concussion, when they are followed by injury to the functions of the lungs or heart. The ribs may be broken, but that in itself is not of great consequence. The broken ribs are, however, liable to lacerate the tissues of the lung, and cause the escape of air or blood into the pleural cavity, and so interfere with the expansion of the lung. So, contusions of the chest wall, even though they do not penetrate the cavity, may cause a contusion of the lung, and set a pneumonic process, or even light up an old tubercular process that has lain dormant.

282. Penetrating wounds of thorax.- Penetrating wounds of the chest likewise are serious, due to interference with the action of the lungs by allowing the entrance of air from the outside, or of blood from the chest wall, so filling the pleural cavity, even though the lung itself may not be injured. Injury to the lung is dangerous principally from the hemorrhage from its tissue. The bleeding from wounds in the edge of the lungs is slight, while that from the region of the root of the lung may be rapidly fatal. Another point of great significance here, too, as in wounds all over the body, is the possibility of infection and the filling of the pleural cavity with pus. Gunshot wounds of the lungs belong in the same category as other penetrating or perforating wounds of the chest. The ball, after it has entered the chest, may be stopped by the bones of the chest wall, or even by the skin just where the ball would have made its exit. The ball may, in some instances, be stopped by the ribs as it strikes them from the inside, and drop back into the pleural cavity and come to rest on the diaphragm. One of the most extraordinary instances of recovery from a wound traversing the whole thorax is the following: A young

soldier fell from a cherry tree upon an upright stake, such as is used in vineyards. It entered the left side between the seventh and the eighth ribs, and the pointed extremity projected on the other side between the fourth and fifth ribs, at the posterior part of the axilla, and to the length of a foot and a half. The young man retained his consciousness and his intelligence, did not appear to suffer much, and after one end of the stick had been sawed off, was conveyed to the hospital. There the stake was extracted without difficulty, and it was found that it had carried a part of the shirt with it. In three weeks the patient was discharged, entirely convalescent.*

283. Heart; nonpenetrating wounds.- Injuries in the region of the heart may produce injury either to the pericardium, with its inflammation, or to the heart itself. Crushing injuries, especially of the chest, are liable to cause rupture of the heart at the base, and death from loss of blood and interference with the action of the heart. Rupture of the heart from disease may also occur, but this is usually evidenced in the condition of the heart. When a person engaged in a quarrel receives a blow over the heart, and dies suddenly, and a rupture of the heart is found, the question may arise whether the rupture was due to the traumatism or to the disease. The case is evidently one that admits of discussion, belonging to that category of cases in which death already pending is apparently hastened by external violence. Whether there was disease of the heart favoring its rupture such as fatty degeneration, ulceration, aneurismal dilatation-must be ascertained, as well as the force of the blow. It must be remembered, however, that rupture may occur spontaneously in these morbid conditions, even when the person is in a tranquil state; but that a fit of anger greatly increases the probability of its occurrence. Hence, the blow upon the chest may have had nothing to do with the rupture, this having been due to a strong excitation of a weakened heart. The same may be said of rupture of the aorta that has been weakened by disease, especially by aneurism.

284. Heart; penetrating wounds.- Penetrating wounds of the heart are always very serious, but not always fatal. Wounds that enter the cavities of the heart are more serious than those that merely produce injury to the heart muscle. Wounds opening the cavities of the heart are usually immediately fatal, but many instances are recorded where patients lived for a considerable period

Many other instances of transfixion in Gould and Pyle's Anomalies and of the thorax, with recovery, are cited Curiosities of Medicine, D. 610.

after the receipt of such an injury. A number of most peculiar cases have been reported of penetrating wounds of the heart, when the bullet has not injured the pericardium. These sound paradoxical but are too well authenticated to be doubted. "Hicquet reports an autopsy of a man who was found dead with a bullet wound in the fourth intercostal space. There was a circular pentrating wound of the right ventricle, although the pericardium, which contained liquid and coagulated blood, had not been injured. The ball was found between the pericardium and the chest wall. Zenker, Zillner, von Hassinger, Borellus, Heydenreich, Ward, Holmes, Gamgee, and Justi, have reported similar cases, some of which involved the left ventricle. In one case the left ventricle had been wounded in two places without there being any wound of the pericardium."

Recoveries after wounds of the heart are almost as remarkable as those after injury to the brain. Conner reports a unique case of a gunshot wound of the heart. The bullet passed through the right and opened the left ventricle and passed out of the left auricle, and became encapsulated in the lower lobe of the right lung. This patient died only after thirty-eight months. There had been profuse bleeding, pneumonia, pericarditis, and endocarditis. Brugnoli reports a similar case. A shoemaker was stabbed in the heart and died after nineteen years and seven months. There was a scar in the right ventricle about 3 centimeters long, and one in the ventricular septum and mitral valve. In a case reported by Dent, death took place one and a half weeks after a penetrating gunshot wound of the heart.

A most singular instance is reported in the "Notes of Observation at the Field Hospital of Rangoon." Here a soldier survived his wound two and a half months; emaciating, however, rapidly, although he was able to walk about. On dissection the course of the ball was traced through the pleura and lung by a cartilaginous canal of condensed tissue, to the root of the lung, where all trace of it was lost. On opening the pericardium, however, a hard body was felt in the apex of the heart which, when the cavity was laid open, proved to be a musket ball lying at the apex of the left ventricle, partly covered by a thin coating of white lymph. heart or evidence of diseased action.

"A number of nonfatal wounds of the heart are cited by Gould and Pyle, Anomalies and Curiosities of Medicine, p. 620.

There was no injury to the The heart was preserved in

System of Practical Surgery, Vol. II., p. 404.

The following two cases are cited in von Bergmann and Bull's System of Quoted in von Bergmann and Bull's Practical Surgery, Vol. II., p. 408.

alcohol and sent to Calcutta. The only manner in which the ball could have found its way to the situation in which it was found must have been through one of the pulmonary veins, as there was no trace of its passage through the substance of the heart. A case which would seem to confirm this idea is mentioned in Smith's Jahrbuch, vol. LXXII., p. 328. A man was struck in the back by a bullet, which entered his thorax, and caused his death in twenty minutes. On dissection it was found that the ball had entered over the sixth rib behind, grazed the lung, and wounded the pulmonary artery. But it could not at first be discovered. It was soon found, however, in the right ventricle of the heart, where it had fallen by its own weight after penetrating the pulmonary artery.

285. Abdomen; nonpenetrating wounds.- Wounds of the abdomen, when nonpenetrating, may be fully as serious as penetrating wounds. Blows on the abdomen are celebrated for the great shock with which they are associated in the "solar plexus blows," which may be followed promptly by death. In addition to this factor of shock, the lax abdominal walls allow of great damage to the internal viscera without any serious signs on the surface. The large blood vessels or the liver or spleen, may be lacerated, and the person die from hemorrhage, or the intestines, kidneys, or gall bladder may be ruptured, allowing the escape of their contents, and infection of the peritoneum, with almost certain death unless properly treated. Of the more remote dangers, perhaps the most important is weakening of the abdominal wall, or the diaphragm, with the possibility of subsequent hernia. These nonpenetrating wounds of great danger are found after falls, crushes, accidents where the victim is run over, and so on. Occasionally in children after run-over accidents the intestine will be found detached from its mesentery, and gangrenous. Rupture of the abdominal organs is much more likely to follow injuries inflicted when the organs are distended, as with food, gas, or fluid of some sort. One case is mentioned by Hofmann of rupture of the stomach, following a stomach washing. There was a split along the lesser curvature of the organ.

There has been a generally accepted opinion that movable kidney may be caused by abdominal traumatisms not penetrating the wall of the cavity. There certainly have been a number of cases of more or less movable kidney, which have been discovered after such injuries. Attention has been called to this condition in some cases on account of the symptoms; while in other cases, probably, it has been because of the more thorough examination to which the person has been sub

jected after such an accident. Harris, in a recent article based on the study of the anatomy of these parts, comes to the conclusion that none of the cases are due primarily to injuries of this character.

286. Abdomen; penetrating wounds.-Penetrating wounds of the abdomen are very serious, principally from the fact that they expose the peritoneum to infection. Injury to the individual organs is of far less significance than the possibility of peritonitis after such wounds. As in the nonpenetrating wounds, injury to the various hollow organs, with the escape of their contents, adds another factor to the possible infection. On the other hand, some most remarkable instances are recorded of penetrating wounds of the abdomen, with recovery. The following case is reported by Mr. Gallway, surgeon in the Royal Artillery:9

"A gunner and driver of the royal artillery had made a murderous attack upon his sergeant with a bayonet, whereby he inflicted two wounds, happily superficial only, upon one leg and arm. Foiled in his efforts of greater success by the seasonable arrival of some other soldiers, the culprit rushed through the barrack-square to escape his pursuers, when the sentry on duty at the gate interposed himself with his carbine, in the attitude of 'charge bayonets' to obstruct him. The consequences of this movement to the other were that as he was rushing through a narrow passage with an impetus which he could not at the time control, he threw himself (not premeditately, it will be understood) with great force upon the bayonet of the sentry, which entered his body an inch to the left of the ensiform cartilage, and, passing through the abdomen, emerged by its point on the left of and close to the spinal column, some inches lower down. When I reached the scene of action, within two minutes after, I found the subject of this wound sitting upon a form in the guard-room, as insensible to any effects from the injury as he was unconcerned at his crime. I could not, therefore, at first believe the statement of his comrades, who told me what had happened, although the bayonet was handed to me bent by the violence to which it had been exposed; but on stripping the wounded man, I discovered the two openings of entrance and exit of the bayonet, corresponding, in form and diameter, to those which the different parts of the weapon would have occasioned. Added to this, the bayonet was withdrawn from his body by a noncommissioned officer, upon whose testimony I could rely; and what is more, this withdrawal was witnessed by a crowd of other solMed. Times and Gaz., May 6, 1854.

Harris, Journ. Amer. Med. Ass., Feb. 13, 1904, p. 411.