Babington speaks of a case of heart-injury, caused by transfixion by a bayonet, in which the patient survived nine hours. Other older cases are as follows: l'Ecluse, seven days; the Ephemerides, four and six days; Col de Vilars, twelve days; Marcucci, eighteen days; Bartholinus, five days; Durande, five days; Boyer, five days; Capelle, twenty six hours; Fahner, eleven days; Marigues, thirteen days; Morgagni, eight days; la Motte, twelve hours; Rhodius, Riedlin, two days; Saviard, eleven days; Sennert, three days; Triller, fourteen days; and Tulpius, two and fifteen days; and Zittman, eight days.
The Duc de Berri, heir to the French throne, who was assassinated in 1826, lived several hours with one of his ventricles opened. His surgeon, Dupuytren, was reprimanded for keeping the wound open with a probe introduced every two hours, but this procedure has its advocates at the present day. Randall mentions a gunshot wound of the right ventricle which did not cause death until the sixty-seventh day. Grant describes a wound in which a ball from a revolver entered a little to the right of the sternum, between the cartilages of the 5th and 6th ribs, and then entered the right ventricle about an inch from the apex. It emerged from the lower part, passed through the diaphragm, the cardiac end of the stomach, and lodged in the left kidney. The patient remained in a state of collapse fifteen hours after being shot, and with little or no nourishment lived twenty-six days. At the postmortem examination the wounds in the organs were found to be healed, but the cicatrices were quite evident. Bowling gives a case of gunshot wound of the shoulder in which death resulted eleven weeks after, the bullet being found in the left ventricle of the heart. Thompson has reported a bayonet wound of the heart, after the reception of which the patient lived four days. The bayonet entered the ventricle about 1 1/2 inches from the left apex, traversing the left wall obliquely, and making exit close to the septum ventriculorum. Roberts mentions a man who ran 60 yards and lived one hour after being shot through both lungs and the right auricle. Curran mentions the case of a soldier who, in 1809, was wounded by a bullet which entered his body to the left of the sternum, between the 2d and 3d ribs. He was insensible a half hour, and was carried aboard a fighting ship crowded with sailors. There was little hemorrhage from his wound, and he survived fourteen days. At the postmortem examination some interesting facts were revealed. It was found that the right ventricle was transversely opened for about an inch, the ball having penetrated its anterior surface, near the origin of the pulmonary artery. The ball was found loose in the pericardium, where it had fallen during the necropsy. There was a circular lacerated opening in the tricuspid valve, and the ball must have been in the right auricle during the fourteen days in which the man lived. Vite mentions an example of remarkable tenacity of life after reception of a cardiac wound, the subject living four days after a knife-wound penetrating the chest into the pericardial sac and passing through the left ventricle of the heart into the opposite wall. Boone speaks of a gunshot wound in which death was postponed until the thirteenth day. Bullock mentions a case of gunshot wound in which the ball was found lodged in the cavity of the ventricle four days and eighteen hours after infliction of the wound. Carnochan describes a penetrating wound of the heart in a subject in whom life had been protracted eleven days. After death the bullet was found buried and encysted in the heart. Holly reports a case of pistol-shot wound through the right ventricle, septum, and aorta, with the ball in the left ventricle. There was apparent recovery in fourteen days and sudden death on the fifty-fifth day.
Hamilton gives an instance of a shoemaker sixty-three years old who, while carrying a bundle, fell with rupture of the heart and lived several minutes. On postmortem examination an opening in the heart was found large enough to admit a blowpipe. Noble speaks of duration of life for five and a half days after rupture of the heart; and there are instances on record in which life has been prolonged for thirteen hours and for fifty-three hours after a similar injury. Glazebrook reports the case of a colored man of thirty, of powerful physique, who was admitted to the Freedmen's Hospital, Washington, D.C., at 12.30 A.M., on February 5, 1895. Upon examination by the surgeons, an incised wound was discovered one inch above the left nipple, 3 1/4 inches to the left of the median line, the incision being 2 1/4 inches in length and its direction parallel with the 3d rib. The man's general condition was fairly good, and the wound was examined. It was impossible to trace its depth further than the 3d rib, although probing was resorted to; it was therefore considered a simple wound, and dressed accordingly. Twelve hours later symptoms of internal hemorrhage were noticed, and at 8 A.M., February 6th, the man died after surviving his injury thirty-two hours. A necropsy was held three hours after death, and an oblique incision 3/4 inch in length was found through the cartilage-end of the 3d rib. A similar wound was next found in the pericardium, and upon examining the heart there was seen a clean, incised wound 1/2 inch in length, directly into the right ventricle, the endocardial wound being 3/8 inch long. Both the pericardium and left pleura were distended with fresh blood and large clots. Church reports a case of gunshot wound of the heart in a man of sixty-seven who survived three hours. The wound had been made by a pistol bullet (32 caliber), was situated 1 1/4 inches below the mammary line, and slightly to the left of the center of the sternum; through it considerable blood had escaped. The postmortem examination showed that the ball had pierced the sternum just above the xiphoid cartilage, and had entered the pericardium to the right and at the lower part. The sac was filled with blood, both fresh and clotted. There was a ragged wound in the anterior wall 1/2 inch in diameter. The wound of exit was 5/8 inch in diameter. After traversing the heart the ball had penetrated the diaphragm, wounded the omentum in several places, and become lodged under the skin posteriorly between the 9th and 10th ribs. Church adds that the "Index Catalogue of the Surgeon-General's Library" at Washington contains 22 cases of direct injury to the heart, all of which lived longer than his case: 17 lived over three days; eight lived over ten days; two lived over twenty-five days; one died on the fifty-fifth day, and there were three well-authenticated recoveries. Purple tabulates a list of 42 cases of heart-injury which survived from thirty minutes to seventy days.
Fourteen instances of gunshot wounds of the heart have been collected from U.S. Army reports, in all of which death followed very promptly, except in one instance in which the patient survived fifty hours. In another case the patient lived twenty-six hours after reception of the injury, the conical pistol-ball passing through the anterior margin of the right lobe of the lung into the pericardium, through the right auricle, and again entered the right pleural cavity, passing through the posterior margin of the lower lobe of the right lung; at the autopsy it was found in the right pleural cavity. The left lung and cavity were perfectly normal. The right lung was engorged and somewhat compressed by the blood in the pleural cavity. The pericardium was much distended and contained from six to eight ounces of partially coagulated blood. There was a fibrinous clot in the left ventricle.
Nonfatal Cardiac Injuries.—Wounds of the heart are not necessarily fatal. Of 401 cases of cardiac injury collected by Fischer there were as many as 50 recoveries, the diagnosis being confirmed in 33 instances by an autopsy in which there were found distinct signs of the cardiac injury. By a peculiar arrangement of the fibers of the heart, a wound transverse to one layer of fibers is in the direction of another layer, and to a certain extent, therefore, valvular in function; it is probably from this fact that punctured wounds of the heart are often attended with little or no bleeding.
Among the older writers, several instances of nonfatal injuries to the heart are recorded. Before the present century scientists had observed game-animals that had been wounded in the heart in the course of their lives, and after their ultimate death such direct evidence as the presence of a bullet or an arrow in their hearts was found. Rodericus a Veiga tells the story of a deer that was killed in hunting, and in whose heart was fixed a piece of arrow that appeared to have been there some time. Glandorp experimentally produced a nonfatal wound in the heart of a rabbit. Wounds of the heart, not lethal, have been reported by Benivenius, Marcellus Donatus, Schott, Stalpart van der Wiel, and Wolff. Ollenrot reports an additional instance of recovery from heart-injury, but in his case the wound was only superficial.
There is a recent case of a boy of fourteen, who was wounded in the heart by a pen-knife stab. The boy was discharged cured from the Middlesex Hospital, but three months after the reception of the injury he was taken ill and died. A postmortem examination showed that the right ventricle had been penetrated in a slanting direction; the cause of death was apoplexy, produced by the weakening and thinning of the heart's walls, the effect of the wound. Tillaux reports the case of a man of sixty-five, the victim of general paralysis, who passed into his chest a blade 16 cm. long and 2 mm. broad. The wound of puncture was 5 cm. below the nipple and 2 cm. to the outside. The left side of the chest was emphysematous and ecchymosed. The heart-sounds were regular, and the elevation of the skin by the blade coincided with the ventricular systole. The blade was removed on the following day, and the patient gradually improved. Some thirteen months after he had expectoration of blood and pus and soon died. At the necropsy it was seen that the wound had involved both lungs; the posterior wall of the ventricle and the inferior lobe of the right lung were traversed from before backward, and from left to right, but the ventricular cavity was not penetrated. Strange to say, the blade had passed between the vertebral column and the esophagus, and to the right of the aorta, but had wounded neither of these organs.
O'Connor mentions a graduate of a British University who, with suicidal intent, transfixed his heart with a darning-needle. It was extracted by a pair of watchmaker's pliers. In five days the symptoms had all abated, and the would-be suicide was well enough to start for the Continent. Muhlig was consulted by a mason who, ten years before, had received a blow from a stiletto near the left side of the sternum. The cicatrix was plainly visible, but the man said he had been able to perform his daily labors, although at the present time suffering from intense dyspnea and anasarca. A loud bellows-sound could be heard, which the man said had been audible since the time of reception of the injury. This was a double bruit accompanying systole, and entirely obscuring the physical signs. From this time the man speedily failed, and after his death there were cicatricial signs found, particularly on the wall of the left ventricle, together with patency of the interventricular septum, with signs of cicatrization about this rent. At the side of the left ventricle the rent was twice as large and lined with cicutricial tissue.
Stelzner mentions a young student who attempted suicide by thrusting a darning-needle into his heart. He complained of pain and dyspnea; in twenty-four hours his symptoms increased to such an extent that operation was deemed advisable on account of collapse. The 5th rib was resected and the pleural cavity opened. When the pericardial sac was incised, a teaspoonful of turbid fluid oozed out, and the needle was felt in an oblique position in the right ventricle. By pressure of a finger passed under the heart, the eye of the needle was pressed through the anterior wall and fixed on the operator's finger-nail. An attempt to remove by the forceps failed, as the violent movements of the heart drew the needle back into the cavity. About this stage of the operation an unfortunate accident happened—the iodoform tampon, which protected the exposed pleural cavity, was drawn into this cavity during a deep inspiration, and could not be found. Notwithstanding subsequent pneumothorax and extensive pleuritic effusion, the patient made a good recovery at the end of the fourth week and at the time of report it was still uncertain whether the needle remained in the heart or had wandered into the mediastinum. During the discussion which followed the report of this case, Hahn showed a portion of a knitting-needle which had been removed from the heart of a girl during life. The extraction was very slow in order to allow of coagulation along the course of the wound in the heart, and to guard against hemorrhage into the pericardial sac, which is so often the cause of death in punctured wounds of this organ. Hahn remarked that the pulse, which before the removal had been very rapid, sank to 90.
Marks reports the case of a stab-wound penetrating the left 9th intercostal space, the diaphragm, pleura, pericardium, and apex of the heart. It was necessary to enlarge the wound, and, under an anesthetic, after removing one and one-half inches of the 9th and 10th ribs, the wound was thoroughly packed with iodoform gauze and in twenty-one days the patient recovered. Lavender mentions an incised wound of the heart penetrating the right ventricle, from which the patient recovered. Purple gives, an account of a recovery from a wound penetrating both ventricles. The diagnosis was confirmed by a necropsy nine years thereafter. Stoll records a nonfatal injury to the heart.