A generation ago a chapter on the surgery of the heart would have been regarded as a surgical fantasy. Today the subject is not only a live one, but experience is constantly accumulating as to the value of surgical intervention in diseases of the heart and pericardium.
MALPOSITIONS OF THE HEART.
The heart may be displaced by congenital or acquired causes. Malpositions of the former type may vary from dextrocardia, where the heart is placed upon the right side, and may be accompanied by a general or partial transposition of the viscera, to those cases where there are defects in the diaphragm or the chest wall, through which the heart protrudes. Dextrocardia has an interest for the surgeon, as, for example, in the following case under the writer’s observation: Disease on the left side which simulated appendicitis, in which the diagnosis was confirmed by finding the heart upon the right side, and later by operation. It was a case of complete transposition.
The acquired malpositions may be due to intrinsic or extrinsic causes. They are pressure effects, usually found in connection with intrathoracic aneurysms and other tumors or collections of fluid, or may be due to change in the shape of the spine in pronounced curvatures. Occasionally the heart is hindered in its action by pressure from beneath the diaphragm. These cardiac displacements are surgically interesting when the cause can be removed by operative measures.
WOUNDS OF THE HEART.
Wounds of the heart are mainly of the punctured or gunshot type. It was formerly considered that injuries of the heart were essentially fatal. This has been disproved by human and comparative observations. As far back as 1855, Carnochan reported a case of gunshot wound of the heart where the bullet was found in the heart substance after the patient had lived eleven days. The museums contain many illustrations of penetrating wounds of the heart or of foreign bodies in it, some of which had remained embedded for many years. Nevertheless the fact remains that the majority of wounds of the heart are fatal, either by arrest of its activity, by shock, by the outpour of blood between it and the pericardium or outside the latter, or later by processes which consume at least a few days, either infective or degenerative. Other things being equal the larger the wound the more dangerous, while an injury to the heart muscle which has not opened one of its cavities is less dangerous than one which perforates them. A punctured wound made by a small stiletto or knife-blade, or even by a needle used for homicidal purposes, may leave but small trace and not prove fatal, save through injury to one of the cardiac vessels, especially a coronary artery.[23]
[23] Illustrating the surgery of foreign bodies in the heart, Jordan has reported the case of a young woman who stated that she had received a blow on the front of the chest the previous day, and showed on examination a small projecting point in the lower part of the third left intercostal space about half an inch from the sternum, which was tender to the touch and seemed to move or pulsate with the heart. It gave to the finger the sensation of a hard substance beneath the skin without any external marking. Upon making an incision and dissecting partly through the muscle the broken end of a black steel pin came into view. After removal with forceps it proved to be a shawl pin, one and one half inches long, with its glass head broken off. The patient remembered having had such a pin in her bosom at the time of the accident. On the following day she had pericarditis. She apparently recovered, but had a relapse, and died on the twenty-fourth day, the autopsy showing pericarditis.
In practically all of these injuries there will be evidence of some external violence. It is of advantage to ascertain the nature of the accident and the character of the missile or instrument. If the depth of penetration of a knife-blade, for instance, can be ascertained more accurate conclusions can be drawn. The special indications of cardiac injury pertain to disturbance of its own function, that is, embarrassment and uncertainty of action, bellows sounds, enlarged area of dulness owing to distention of the pericardium with blood, dyspnea, and distress, and sometimes pain and syncope. These symptoms and signs do not appear instantaneously, but increase in severity.
Treatment.
—In such an emergency everything possible should be done to relieve the embarrassment of the heart’s action—the head should be kept low, the body absolutely quiet, and nervous excitement should be allayed at once with a full dose of morphine. Heart stimulants should not be given. Ice applied over the chest will help quiet cardiac activity. If the patient be not failing too rapidly operation is advisable, and should be done in a well-equipped hospital, with trained assistants. The purpose of the operation is to expose the injured portion of the heart substance and close it with suture; at least to remove the fluid or partially coagulated blood within the pericardium.[24] As it is not always possible to expose the heart without opening the pleural cavity, there should be at hand not only the means for a tracheotomy, but an apparatus by which artificial inflation of at least one lung can be effected. Pneumatic cabinets have been devised for this purpose, especially by Sauerbruch, where a difference of pressure can be maintained between the outside and the inside of the cabinet, so that the chest may be widely opened and the lung not collapsed; but such a cabinet is available in few places in the United States. The improved Fell apparatus, by which a mask is kept over the face and pressure maintained with the foot through a bellows, has been found useful. Even in the absence of such apparatus the surgeon should not abstain from the effort, though it may appear less promising.