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dividing the structure of the diaphragm, and of withdrawing the parts protruded into the thorax, can, I fear, only be attempted with a hope of success in what may be termed secondary cases,—where the sufferer has recovered, with a hole in his diaphragm, through which, after a time, portions of the viscera of the abdomen ascend into the thorax, and become incarcerated in the first instance, and subsequently strangulated, from distension of the hollow viscera.-G. J. G.”
It will be observed, that vomiting and excessive thirst were prominent symptoms. Similar symptoms are alluded to in a case reported in the Lancet of the 4th of July, 1828, page 421, “awful thirst" and “ anxiety" are the terms employed. There are two cases of cure recorded in the Medical Times and Gazette, vol. xxxvi, page 199, and Lancet of the 4th of July, 1828.
Parée relates a case in which, at the autopsy, he fancied that the stomach was absent, but found it, in the thorax, distended with air. The stomach had passed through a hole in the diaphragm half an inch square. In another case, reported by the same surgeon, in which a ball entered at lower margin of the sternum, and passed out between the fifth and sixth ribs, the wounded man appeared after a time to have recovered, except that he had frequent attacks of colic, and dared not to eat a full meal. Eight months after the receipt of the injury, he died during a severe attack of colic. A great portion of the colon was found in the thorax. The hole in the diaphragm was the size only of a pea.
The statement has been passed down by writers, that wounds affecting the tendinous portion are mortal; while those affecting the fleshy fibres terminate more favourably. Any one curious in this question will find a collection of such cases in Bonetus. It is remarkable that the diaphragm is not more frequently wounded, when we consider that, at the moment of a forced expiration, it'may rise to the level of the fifth rib. The following case of wound of the @sophagus, given by Riverii, page 684, is the only one I have met with in my reading, and the minute description given of the symptoms will be useful for diagnosis in future cases :
“ Dominus de Roques, junior, Eques cognomi. natus, Salsæ obsidione vulnus ex sclopeto accepit in parte superiori et media sterni, quod oblique ad dorsum ferebatur, et sex digitis transversis à spina dorsi exitum habebat. Statim ab inflicto vulnere dolores punctorios, acutissimos in @sophago percipit; ac si spina illi partes infixus haberet, et quia a sanguine suffocabatur, maximis conatibus illum nitebatur excernere ; ac tandem post longos frequentesque conatus, multam sanguinis excretionem, quia plurimus pelves impleverat, dolor
sophagi punctorius omninò desijt. Post multos dies æger alvum deponendo, eosdem in ano dolores 99
dividir drawing : fear, o what r. sufferer: phras... the vir and ! subse. hol!"
sunt.” Casserius, also, gives several instances of cure, also M. de Garengeot, also M. de la Martinière. No case of wound of the trachea came under my immediate care. In the Director General's Report, there is noted under “gun-shot wounds of the neck," only one hundred and twentyeight men, and nineteen officers. The per centage in the former, to the total number wounded, viz. 12,094, being only 1:7; but, of these, only five had actual lesion of the parts ; viz., one of the pharynx, two of the larynx, one of the larynx and esophagus, and one of the trachea. Of these, one died, one went to duty, and three were invalided. The fatal case occurred in the wound of the pharynx. Of the nineteen officers, only three had actual lesion of the parts; two died, and one was invalided. The others were simple flesh contusions, and wounds. Certain cases, where neither the lungs nor large vessels were wounded, but rapid and fatal sinking occurred, may be explained by the supposition that the thoracic duct had been injured. No special case of wound of the par vagum or other thoracic nerve is noted.
ON THE TREATMENT OF PENETRATING WOUNDS OF
This division of the treatise will be discussed under the heads of Local and General Treatment.
1. LOCAL TREATMENT.—In order to detect the foreign substance known or suspected to be lodged in or about the thoracic cavity, a very careful exploration is to be made ; but the less probing and poking the better, unless obvious reasons demand manual interference. As far as regards the probable presence of splinters of bone, we may be somewhat guided by observing whether the ball or projectile has passed through the cartilage, or the solid osseous portion of the rib or ribs; in the latter, the presence of splinters is more to be apprehended than in the former case. John Bell, at page 281, says: “ The finger should always be introduced gently; and this way of probing should never be repeated, unless when we are sensible of there being many splinters of bone.” Erichsen, at page 296, says: “In these cases, if the surgeon