It has been proved that a large pro portion of those who survive an injury to the heart a few hours or days die either from loss of blood or compression of the heart by the blood effused within the pericardium. Theoretically either of these dangers can only be met by an operation, and practically a very fair number of successful operations bids us hope that in the future a satisfactory percentage of successes may be reported.
At present it does not seem justifiable to operate except in those rare cases when the patient is evidently failing rapidly and yet not moribund at the time of operation.
The technique is described in Section VI.
The later dangers of infection are met by the routine treatment of septic wounds—drainage, wet dressings, irriga tion, etc.—and of suppurative pericar ditis, mediastinal abscess, etc., as the case may be.
The pericardium and heart are not re gions where surgical intervention is al ways contra-indicated. Before interven tion is attempted the condition of shock that is generally present must be over come. This is accomplished by the intravenous injection of physiological serum and other fluids. Intervention should not take place while the heart is weak, and nothing should be done to enfeeble it. Anaesthetics should be avoided or used only in a very slight amount, without full anesthesia.
The method of intervention is influ " eneed by the form of injury that re quires it. If the injury is of the nature of a puncture or prick as by a needle, the foreign body should be removed. If the volume of the foreign body is greater it is better to operate where everything is in sight rather than to trust to the closure of the wound by a contraction as the body is gradually withdrawn. The pericardium and, if necessary, the heart is laid bare, sutures are placed in posi tion, the foreign body removed, and the wound closed immediately by drawing the sutures.
Where an incised wound of the heart is suspected the symptoms must be the guide. Secondary intervention has suc ceeded in a number of cases, and inter vention must be postponed till the symp toms indicate the necessity. The compli cations to be watched for are haemor rhage and pericarditis.
In hemorrhage immediate intervention is never indicated, as spontaneous arrest often cures. Therefore, if the area of pericardial dullness remains stationary and does not increase, expectant treat ment is indicated. When, however, there is an aggravation of the general condi tion, with pallor, weak pulse, syncope, an augmentation of prcordial dullness, weakening of the sounds of the heart, and recurrent external hemorrhage, in tervention is indicated. When possible
the track of the wound should be exam ined before opening the pericardium. Cestau (Gaz. Heb. de 11110.d. et de Chir., No. 17, '9S).
Ninety cases of wounds of the heart and pericardium, in which the lesion was discovered during operation or at the necropsy, tabulated. In 70 eases death occurred without intervention, 56 from internal hemorrhage, 12 from infection, and 2 from cerebral lmnorrhage. The nature of the instrument causing the wound is reported in 7S cases; nearly all of them were penetrating wounds from small arms; 43 of them from a knife. The right ventricle was injured in 31 cases, the left ventricle in 26 cases, the right auricle in 6 cases, and the remain ing cases were of the left auricle, great vessels, and unclassified. In 45.5 per cent. of the cases there was also a wound of the pleura, and in many of the other cases other organs were injured. Peri cardotomy followed by tampon of gauze was practiced in 3 cases, with cures in all. Eight pericardotomies followed by suture of pericardium were followed with 3 recoveries and 5 deaths. In 5 cases in which wounds of the heart were su tured followed by packing or suture of the pericardium there were 2 cures and 3 deaths, one of them from an independ ent cause. The time intervening be tween the accident and death varies from some minutes to several hours. E. Loison (Revue de Chir., Feb. 10, '09).
Clinical experience has shown that wounds of the heart are not so grave as is generally supposed, and that recov ery may follow even a wound extending into one of its cavities.
Death in most instances of fatal heart injury is due to haemorrhage. The most urgent danger, however, in eases of pene trating wounds of the heart, especially those of the ventricles, is shock due not so much to anaemia as to direct irritation and disturbance of the wounded organ. This condition of shock should be treated not by the application of stimulants, but by prompt intervention of the surgeon in enlarging the wound in the pericar dium, in removing clots from this sac, in exploring the injured heart, and in closing the wound of its wall by suture. Another but less frequent cause of death in cases of wounded heart is the entry of air into the wound and consequent gaseous embolism.