Some observations on penetrating wounds of the heart

SOME OBSERVATIONS WOUNDS LIEUT.

ON PENETRATING

OF THE HEART

COL. J.

A.

B. HILLSMAN

MEDICAL CORP, ROYAL CANADIAN ARMY T is difficult

I

heart.

to justify

The condition

as a ruIe rapidIy

wound

tearing

and rapidly mostly

Iarge

fatal

from

a paper

is fortunately

fatal.

Death

hoIes

into

hemorrhage.

knife stabs

in the pericardia1

sac.

on penetrating

rare in civilian

is usualIy

the

wounds

The smaIIer

practice

the resuIt

cardiac

cavities wounds

and are accompanied

of the and

of a pistol

with

massive

of the heart

are

by a smaII opening

In this type of wound,

hemorrhage

from the

heart cannot escape through the smaI1 pericardia1 opening and squeezes the heart into immobility. Most of the recoveries reported from heart wounds are of the stab wound variety in which the surgeon

has been

abIe

to decompress

cardial pressure kills the patient. In war wounds, it is possibIe the heart in which the patient of time.

The surgical

results

viding there are not other Canadian

FieId

encountered

Surgical

recovered.

in these in the

penetrating

During

of the heart.

wounds

Theatre

of

Iength

my service

prowith a

of war

One of these

I

patients

The other three were patients died and one

this paper by describing

necessary for Iong term survival in heart difKcuIties in diagnosis and operation.

intraperi-

are satisfactory

European

wound and recovered. wounds. Two of these

I hope to justify

before

for an astounding

patients

compIications. Unit

heart

to receive

wiI1 survive

four such wounds

had an uncompIicated complicated by other

the

wounds

the conditions

and to report

the

In war, high explosives cause about seventy per cent of the wounds encountered. The fragmentation of sheIIs and mortar bombs wiI1 produce missiIes of varying sizes traveling at exceedingIy high veIocity. spatter These

Minute against

bits of meta the sternum

traveling

at this

or a rib and then

high veIocity

penetrate

bits of metal wiI1 tear Iarge hoIes in the pericardia1

can

the heart. and pleura1

sacs but for some pecuIiar reason make onIy smaI1 hoIes in the heart muscuIature. The combination of a Iarge communication between the pericardia1 sac and some other body cavity with reIativeIy small wounds in the heart is necessary for Iong term surviva1 of the pa305

306

HILLSMAN-WOUNDS

tient.

OF THE HEART

The Iarge hole in the pericardium

and prevents From

squeezing

aIIows the blood to escape

of the heart.

direct observation

in al1 four patients,

the smalI hole pene-

trating into the heart cavities does not bIeed as freely as was formerly thought. Bleeding occurs only in systoIe and consists of small spurts

of blood.

astonishingIy one third

The

amount

Iost with

smaI1. The Iargest

each

penetrating

of an inch in diameter.

The

heart

contraction

bIood from this wound

about one inch in the air during systole

is

wound seen was about rose

and each spurt lost approxi-

mateIy one teaspoonful of blood. It is impossible to state how Iarge a cardiac wound wouId have to occur before continuous and rapidly fata

hemorrhage

follows.

It is certainly

true, however,

that wounds

up to one-third of an inch in diameter, whethel in ventricle or auricle, do not bIeed furiously or continuously, but only in smaI1 spurts during systoIe. In none of these cases was the diagnosis

of a penetrating

wound

of the heart made by clinical examination. The perforation was suspected only by the anatomica location of the entrance wound. CarefuI

auscuItation

did

clinical

picture

consistentIy

was

not

revea1

any

one

abnorma1

of profound

sounds. shock

The

usually

accompanied by dypsnea. Since the left pleural cavity contained a Iarge quantity of blood and air in three of the cases this was not surprising. Diagnosis

was made

by suspecting

and exploring.

In the

pected cases carefu1 wound toiIet was performed, preferabIy local anaesthetic. Through the wound a finger expIoration

sus-

under of the

pericardia1 sac was made. When a hoIe was found in the pericardium the patient was switched to pressure anaesthesia and a rib resected over the site of the pericardia1 sucked

out and the opening

watched.

fiIIed with bIood the diagnosis was made. The surgica1

approach

opening.

AI1 the bIood in the sac was If the pericardia1

of a penetrating

to the

heart

was,

sac again

wound of the heart in a11 four

patients,

through a trapdoor incision over the third, fourth and fifth ribs on the Ieft side. These ribs were resected subperiosteaIIy, about a half an inch from the sternum and again about three inches laterally. The intercosta1 muscIes were cut, and the fIap turned back. The heart wounds were a11 easiIy Iocated and sutured with interrupted siIk. The pericardium was Ieft open. In a11 cases the incision was closed by first bringing the intercostal muscles together and turning down a flap from the Ieft pectoraIis major muscIe. This rendered

HILLSMAN-WOUNDS the wound

airtight.

The

chest

put on the usuaI resuscitative

OF THE

was then

HEART

aspirated

and the patient

measures.

CASE REPORTS CASE I. H. C. was thirty-two years of age. He had multipIe mortar wounds. The time of wounding was 2~00 P.M. and time of operation was I I :30 P.M. Three smaI1 wounds were seen in the front of the chest. One of these wounds was in the left fourth interspace one inch from sternum. Patient was in severe shock. Blood pressure 70 systolic, 40 diastolic. Apex beat was not dispIaced. The patient was quite dyspneic and cyanotic. Thoracentesis obtained 1200 cc. of bIood and 400 cc. of air. Wound in the fourth interspace was trimmed and wound toiIet carried out under IocaI anesthesia. Finger expIoration demonstrated a Iarge hoIe in the pericardia1 sac. Pressure anesthesia was given and the fourth rib resected. The pericardia1 sac was found ful1 of blood and sucked dry. Observation showed that the sac continued to hII with bIood. The pericardium was exposed through the trapdoor incision. The opening in pericardium was enlarged and two wounds were found in the heart muscIes. The hoIes were about one inch apart, four mm. in diameter, and presumabIy one Iay over the right ventricle and the other over the Ieft ventricIe. From both wounds a stream of bIood spurted with each contraction of the heart. No Ieakage occurred at any other phase of the heart beat. The wounds were sutured with interrupted silk and hemorrhage easiIy controhed. The pericardia1 sac was Ieft wide open and the wound closed without drainage. The chest was aspirated and 600 cc. of air and bIood removed. Condition was only fair after the operation but oxygen and transfusions improved the patient considerabIy. The folIowing morning the chest was again needled and a dry tap obtained. This patient continued to improve and was evacuated on the eighth day. CASE II. M. H. was a fifty year old German prisoner, with a singIe shell wound. The time of wounding was 6 P.M. and time of operation 12:30 A.M. This patient was in exceedingly poor condition. BIood pressure was 90 systolic and 60 diastolic. Then there was a singIe wound in fourth interspace about one inch from the sternum which was sucking air. The patient was very frightened and hysterical. In spite of his condition and Ianguage diffrcuIties it was quite obvious that he was suffering severe pain in his left shouIder area. He wouId grab and rub the shoulder and scream at the top of his voice. Morphine had no effect on him and he did not improve with transfusions. We were forced to operate in order to cIose the sucking wound. LocaI anesthesia was impossible. Under pressure anesthesia a hasty debridement of the wound was performed foIlowed by finger exploration of the pericardial sac. A Iarge hole was found in the sac. The fourth rib was resected and the sac found full of bIood. It was sucked dry but soon refilled.

HILLSMAN-WOUNDS The pericardium

OF

was exposed.

THE

HEART

The tear in the sac was enlarged

was easily seen that two wounds in the heart were present. had divided penetrated

the descending

and was situated

hole in the ventricIe the heart

beat.

ventricuJar

artery

Both

wounds

artery.

the patient’s

The

condition

couId not be made. and adrenalin

was not bleeding.

and auricle

wound incIuded

coronary

of the left coronary

artery

The second was apparentIy

and had

the wound of exit

on the upper IateraI side of the heart in the left auricular

area. The torn coronary

left

branch

the left ventricle.

and it

The first wound

BIood

spurted

from the

but not at any other phase of The

suture

the torn ends of the descending

were sutured

branch

coronary

became

The

on systole

vein was probably

desperate

heart

with silk.

stopped

beating

of the

also torn

at this point careful

into the heart muscle started

in the

entireIy.

but

as

observation

Careful

massage

it again. The chest was quickly

cJosed. Aspiration

obtained

fusion improved in fair shape. morning

1,800 cc. of air and blood. Oxygen

the patient’s

Throughout

the patient

characteristic

disease.

difZcuIt

pulling off the oxygen

the condition

Morphine

remained

400 cc.

reJief. The puIse became

quiet.

and rubbing

weak, thready,

not be maintained.

thirty-two

The

patient

rales in both bases.

showed

Tap-

and irreguIar.

The bJood

more

and more

the typical

picture of

as the day wore on. By evening he presented

pleura1 cavities

He was constantly

became

dyspneic both

so

of bJood and 300 cc. of air but gave no

could

failure with numerous

In the

his Ieft shoulder.

pressure cardiac

fair.

the fright-pain

in heavy doses was given but

to keep the patient

mask, screaming

ping of the chest obtained noticeabIe

the night

and bIood trans-

and he was finaJIy sent to the ward

was fully awake and again exhibited

of coronary

it was exceedingIy

condition

no air or blood

Repeated

present.

This

aspiration patient

of died

hours after operation.

The heart was removed examination. infarction

Report

at autopsy

and sent back to a Base Hospital

in the region of ventricuIar

wound with extensive

muscle necrosis.

This case, we beIieve, died a cardiac death as the result of the tearing descending

branch

of the Ieft coronary

In view of the damage outstanding

CASEIII.

for

received some time Jater stated that there was marked

to this artery

artery the fright

in this case, is of particular E. J. a patient twenty-six

wound. The trme of wounding

with subsequent

of the

infarction.

and the shoulder

pain, so

interest. years of age suffered a singJe she11

was I ~30 A.M. and time of operation

6:oo

A.M.

There was a single wound of entrance just above and medial to the Ieft nipple. The Ieft fourth rib was shattered and the wound was sucking air. The patient was deeply systolic and 40 diastolic.

shocked and dyspneic. Blood pressure was 68 Wound toilet was carried out under Jocal anes-

thesia.

revealed

Finger

was then resected.

expIoration

switched

to pressure

The pericardia1

a Iarge hole in the pericardium.

anesthesia

and the

shattered

Patient

fourth

rib

sac was found full of bIood and sucked dry. The

I IILLSMAN-WOUNDS sac filled again

with blood.

the pericardium

exposed.

about

The

OF THE

usuaI trapdoor

The pericardia1

opening

one inch Iong was seen in the anterior

The wound appeared the ventricIe

incision

of the right ventricle.

of air withdrawn

cc.

without

into place.

into the upper anterior This

was connected

had deveIoped

also. Oxygen

there.

Post mortem or the shattered

aspect

fourth

pIeura.

This

soft tissues

fragment

had IittIe effect.

in the left secondary

LittIe

showed that

fragments

the right

condi-

from either the heart

the she11

but had also lobe. Another

and torn a hole in the right

through

The pressure

bronchus

pneumo-

on this side

The patient’s

to the upper left pulmonary

towards

relief was

hours after operation.

had penetrated

of the back.

drain.

tap was instaIled

rib had not only wounded

had penetrated

we were A needle

It was found that a pressure

He died twenty-eight examination

obvious

his and

of the left chest and strapped

An underwater

torn a large hole in the bronchus fragment

was not sutured.

pneumothorax.

to an underwater

and bIood transfusions

tion deteriorated.

It was quite

with pressure

noted. The right chest was needled. thorax

The heart

The Ieft chest was aspirated

relief.

dealing \vith a wound of a bronchus was inserted

hoIe into

one third of an inch in diameter.

quite dyspneic.

and

and a tear

was in fair shape when he left the table but soon after

return to the ward became 4,000

was made

type and the actuaI

wound was cIosed with interrupted silk. The pericardium Th e wound was cIosed in the usua1 manner. The patient

309

was enlarged

aspect

to be of the tangentua1

was approximateIy

HEAKT

the right Iung and into the

pneumothorax

but as there

arose from the hole

was a direct

communication

between the right and Ieft pleura1 cavities it manifested itseIf on both sides. The heart was removed and sent back to a Base Hospital. The pathological report did not reach us. CASE IV. wounded

belly peering in front. fourth

S. S. was a twenty-two

by a rifle bullet.

This

year

old patient

man was on patrol

been

over a sIight rise in the ground when a sniper shot him from

The wound of entrance rib. The

time

hours. On admission and 48 diastolic.

interva1

was just

between

he was in profound

He was not dyspneic

inside the nippIe line above the

w-ounding and operation shock.

Blood pressure,

but the abdomen

al1 over. Intestinal sounds were absent. The &est under Iocal anesthesia and finger expIoration carried inch in diameter sure anesthesia

who had

and was lying on his

was found in the pericardia1 and the fourth

rib resected.

systolic

was rigid and tender wound was trimmed out. A hole about one

sac. Patient The pericardial

full of blood. This was sucked dry onIy to refill again. The pericardium was exposed and opened freely.

was five 72

was given pressac was found

A tangentual

wound

of the apex was immediately seen. The wound was about one inch long in the muscle but the opening into the ventricular cavity was about three miIIimeters in diameter. A smaI1 stream of bIood spurted from it during systoIe.

The wound was easiIy sutured

with silk. It was then seen that the

HILLSMAN-WOUNDS

310

OF THE HEART

hulIet wound had penetrated downwards through the diaphragm and that most of the bIood probabIy had escaped into the peritoneal cavity. The chest wound was hurriedly sutured in the usua1 manner and the Ieft pleural cavity needIed. Eight hundred cc of air and 200 cc of blood were obtained. After further resuscitation an upper right rectus incision was made. The abdomina1 cavity was found ful1 of bIood and was sucked dry. No perforations could be found. It was noticed that there was considerable retroperitoneal hemorrhage. The gastrocolic omentum was incised and two hoIes found in the posterior aspect of the stomach. The buhet had pIunged into the Ieft lumbar muscIes without injuring either the spleen or the kidney. The perforations of the stomach was sutured with silk and the abdomina1 wound cIosed. The patient, after a few stormy days made an uneventful recovery. It

is to

studies

be

could

operation, ing the ticuIarIy

regretted

not be made

when

resuscitation

postoperative interesting.

that

eIectrocardiographic

in these

cases.

measures

During were

and

roentgen

the interva1 instituted,

before

and

period these studies woud have UnfortunateIy this type of equipment

dur-

been parwas not

carried by FieId SurgicaI Units. In justice to the RoyaI Canadian Army MedicaI Corps I fee1 some expIanation shouId be made of the Iong time interva1 between wounding and operation. AI1 these cases time tient

were

evacuated

to us under

very

trying

circumstances.

interva1 incIudes that required for resuscitation had arrived at the advanced SurgicaI Centre.

after

The the

pa-