[24] Suture of Heart Wounds.—Stewart has tabulated 60 cases of suture of the heart reported up to May, 1904, with a remarkably high recovery rate of 38 per cent. (Amer. Jour. Med. Sci., October, 1904). Of the 60 cases 55 were stab wounds and 5 were gunshot wounds, 2 of the latter recovering. In 4 of the cases the coronary artery was injured, and only 1 of these recovered. The injury occurred through a puncture while suturing the heart, and an extra suture was necessary in order to control it. Of the 60 cases the left ventricle was wounded thirty times, with 30 recoveries. The right ventricle was wounded 21 times, with 7 recoveries. The operation has only been practised for about ten years. The results reported certainly justify its performance in all cases of this kind.
In the operative procedure one may feel inclined to utilize the already existing wound, either as a part of his incision or for exploratory purposes, or he may decide to disregard it. The operation consists in raising an osteoplastic flap on the chest wall, by which the pericardium and then the heart are exposed. The incision through the skin is extended to the bone and only enough of the soft structures separated from the ribs and cartilages to expose them sufficiently for division. Ordinarily it would be preferable to divide the third, fourth, and fifth costal cartilages at their rib terminations, and then to turn up the flap with its base at the sternum, though the procedure can be reversed to almost as good advantage. The cartilages and the ribs may be divided with the costotome and the rest of the structures with stout scissors. The flap, having been gently elevated at the edge, is separated from the underlying cellular tissue and pericardium until its sternal margin has been reached. When detached it may be sprung upward, and thus a complete window is made in the chest wall. When more room is desired bone and cartilage may be cut away with a rongeur.
Fig. 136
Result after thoracotomy for heart wound. (E. J. Meyer.)
The pericardium being thus exposed may be found much distended or altered by the imbibition of blood. It should be opened to an extent sufficient to permit evacuation of its bloody contents and sufficient exposure of the heart to permit not merely inspection but suture of any wound in the heart substance. This is exceedingly difficult on account of motions of the heart, and the insertion of sutures will be as difficult as trying to hit a flying target. Nevertheless it may be done in many cases. Unless imperative, a coronary artery should not be included in the heart suture. Hemorrhage from the heart being checked the pericardium is then to be united, preferably with hardened catgut sutures, with or without drainage. In most instances the former is the better plan, and the drain may be of the cigarette type, that is, gauze wrapped in oiled silk.
Should it be found that the pericardium alone is injured and not the heart the case may be regarded in a more favorable light.
There are sufficient cases on record where procedures analogous to the above have been practised to justify the attempt in every case. Hardened animal sutures may be used in the heart substance, and the interrupted method will probably prove the better. A suture which will hold firmly for three or four days will suffice, as has been proved on animals.
RUPTURE OF THE HEART.
Rupture of the heart can scarcely be considered a surgical condition, though it has frequently been one of medicolegal interest. It may, however, afford a sudden and unexpected termination to surgical cases. The cardiac muscle may be so softened by the poisons of diphtheria and other acute infections as to be greatly weakened, even though an intubation or tracheotomy has apparently afforded security.