Surgical intervention is indicated just as much in simple wound of the pericar dium as in an injury involving both this membrane and the wall of the heart. The technical difficulties are very great. A flap of the thoracic wall—including the left half of the lower extremity of the sternum and the third, fourth, fifth, and sixth costal cartilage — recommended. Podrez (Rev. de Chir., May, '99).
Experiments upon rabbits show that they bear the introduction of a needle into an unexposed heart better than when the heart has been exposed. Re view of the surgery on the subject shows that a needle introduced into the human heart must be immediately ex tracted, and that exposure of the heart for its removal will not always be necessary. After the first few days ex posure of the heart will be dangerous. The needle can, however, under favor able circumstances remain in the heart. To extract larger foreign bodies. the heart must be exposed. V. Oppel (Ar chiv f. klin. Chin. lxiil. No. 1. 1901).
A review of cases of stab wounds of the heart justifies the following conclu sions:— 1. The time has arrived when a wound of the heart should be operated on with as little hesitation as a wound of the brain, with the expectation, under cor responding conditions, of getting equally good results. The mortality must inev itably be high,—not from the operation, but from the injnry,—especially if all cases, including desperate ones, be un dertaken. Selection of cases who have survived five or more hours after receiv ing the wound would give a good per centage of recoveries, but such selection is not to be recommended.
2. In all cases of wounds in the region of the heart, with symptoms threatening life, an exploratory operation should be done by making an osteoplastic flap by dividing the fourth and fifth costal car tilages at their attachments to the sternum and the ribs about one inch ex ternal to their attachment to the carti lage, somewhat according to the method of Roberts. This flap turned up as a door on a hinge gives a good view of the pericardium and can easily be enlarged upward if more room is required.
3. While early and speedy operation is often essential to success, yet the im portance of asepsis cannot be too strongly emphasized on account of the great danger of pericarditis and empy ems. If there has been much hemor rhage a quantity of physiological salt solution, approximately equal in amount to the blood lost, should be injected into a vein while the surgeon is operating on the heart if it has not been done sooner.
George Tully Vaughan (Medical News, Dec. 7, 1901).
Foreign Bodies in the Heart.—As a rule, the lodgment of a foreign body in the pericardium or heart, whether by trauma or ulceration, is rapidly and ir retrievably fatal. Exceptionally, how ever, some individual evidences this dition unconsciously for a number of years, and dies of intercurrent disease. [Beer (Cincinnati Lancet-Clinic, xi, 496,'9g3) reports an autopsy on the body of a veteran of the Civil War who had carried a bullet in the wall of his heart for thirty-seven years without a symp tom.
Elmigcr (Allg. Zeits. f. Psych., liv, 1101, '98) reports a similar case: a needle found in the heart-wall three years after it was forced into the chest. LEWIS A. STIMSON and EDWARD L. KEYES, JR.] In general, the prognosis is quite as fatal as for other wounds of the heart.
The heart sometimes tolerates foreign bodies very well, and again a slight in jury proves fatal. Among foreign bodies found in this organ, besides bullets and needles, which are the most common, are splinters of wood, fish-hones, etc. Even the ubiquitous hat-pin has been discov ered (Langier). Bullets have been found capsulated in the heart for many years; in the right ventricle six years (La tour) ; in the wall of the ventricle for twenty years (Balch); and for no less than fifty years in the pericardial sac. It must be observed in passing, however, that these were the old-fash ioned round balls; few conical balls will be stopped by the heart, and still fewer, if any, of the most recent projectiles of small calibre and extreme penetration.
The extent of the wound does not seem to bear any decided relation to the duration of life, for while Steiner's ex periments seem to prove that simple puncture by a needle is not very dan gerous, yet several cases are on record of immediate death resulting from needle wounds, accidental, homicidal, or other wise. Again, in the cases where recovery took place the damage was much greater than any that could be inflicted by a needle. In Brugnoli's case the mitral valve was implicated; in Conner's case, one cusp of the aortic valve; yet the patients survived for years. Editorial (Jour. Amer. Med. Assoc., June 13, '96).