CHAPTER II
Wounds of the Heart (Including RetainedForeign Bodies), Mediterranean (Formerly North African) Theater of Operations
Lyman A. Brewer III, M.D., and Thomas H. Burford, M.D.
INCIDENCE
In World War I, as Makins (1) pointed out, casualties with cardiacwounds who survived to come under the care of a surgeon were hit either byrelatively small missiles or by missiles traveling with reduced degrees ofvelocity. The same situation prevailed in World War II. In the 2? years thatelapsed between the first Allied landings in North Africa on 8 November 1942 andthe end of hostilities in Italy on 2 May 1945, only 75 of the 2,267 thoracic andthoracoabdominal wounds encountered by the teams of the 2d Auxiliary SurgicalGroup were instances of cardiac or pericardial injury. This is an incidence of3.3 percent. Of the 75 injuries, 18 were examples of pure pericardial trauma. Inthe other 57 cases, the heart was involved (table 5). No single team encounteredmore than 10 cases.
In 1 of the 75 cases, the only stab wound in the series, the wound wasself-inflicted. The remainder of the injuries were all battle-incurred, in 53instances from shell fragments and in 21 from small arms fire. In 2 of the 18pure peri-
TABLE 5.-Distribution of injuries andanatomic involvements in 56 combat-incurred cardiac injuries1
Type of injury | Cases | Anatomic involvement | ||||||
Ventricles | Auricles | Both | ||||||
|
| Right | Left | Both | Right | Left | Right | Left |
Contusions | 16 | 5 | 7 | 3 | 1 | --- | --- | --- |
Lacerations | 10 | 2 | 7 | --- | 1 | --- | --- | --- |
Contusions and lacerations | 10 | 2 | 5 | 2 | --- | --- | 1 | --- |
Perforating and penetrating | 19 | 3 | 7 | --- | 7 | 2 | --- | --- |
Embolic to heart | 1 | --- | 1 | --- | --- | --- | --- | --- |
Total | 56 | 12 | 27 | 5 | 9 | 2 | 1 | --- |
1This table does not include a self-inflicted stab wound, from which the patient recovered. It also does not include 18 combat-incurred pericardial injuries, 3 of which were fatal.
50
cardial injuries, the damage was caused directly by ribfragments, and in at least 1 other case, extensive contusion of the myocardiumwas caused by rib fragments which acted as secondary missiles (fig. 11). In 43cases, the injuries were confined to the chest; in the other 32 cases, thewounds were thoracoabdominal.
As these statistics indicate-75 cardiac wounds in 2,267 thoracic andthoracoabdominal injuries-wounds of the heart were not observed with any greatfrequency in forward hospitals of the Mediterranean theater. The reason, asalready intimated, is that they were usually-though not always (fig. 12)-promptlyfatal. These figures take no account of immediately fatal wounds, nor do anyreliable statistics exist concerning them. In the analysis of 1,000 battlefielddeaths by Capt. William W. Tribby, MC (2), it did not prove practical toperform routine autopsies, and even this remarkable series therefore contributesnothing really definite concerning the number of casualties with cardiac woundswho died on the field.
It should be remembered in reading this chapter that, as willbe discussed in more detail later, in every instance in this series, the cardiacinjury was only a single feature of the trauma. In addition to their cardiacinjuries, all of these casualties had sustained more or less extensive wounds ofadjacent thoracic structures, and the chest wounds in many instances werefurther complicated by serious wounds of other parts of the body.
51
The data in these cases, most of which were cared for understress of battle conditions in forward hospitals, are remarkably complete,thanks to the special records kept by the teams of the 2d Auxiliary SurgicalGroup. The preservation of essential data, including roentgenograms andelectrocardiograms, was facilitated by the peculiar and often dramatic nature ofthe injury, which attracted the attention of shock officers and internists aswell as surgeons. Personal notes on the records, and personal comments by themedical officers who cared for the patients, provided more information in thesecases than was usually obtainable from even specially kept clinical records.
CLINICAL PICTURE AND DIAGNOSIS
Diagnostic Considerations
The preoperative diagnosis of injuries of the heart was notonly difficult in itself but was sometimes not made because examination was notdirected toward their discovery. One reason for the omission was the impressionthat
52
casualties with cardiac wounds did not live long enough to arrive at aforward hospital. As a result, symptoms and signs arising from the cardiacwound, particularly anoxia, were often attributed to other injuries that werepresent and that complicated the diagnosis. There is no doubt that more carefulclinical examinations would have led to an increase in correct diagnosis. It issignificant that the same three medical officers made all seven observations ofarrhythmia in the 2d Auxiliary Surgical Group series. As with anoxia, therelation of tachycardia to the cardiac wound had to be based on ruling out allother causes for this sign. No single symptom or sign was usually sufficient toestablish the diagnosis of cardiac injury.
The patient was usually designated for surgery on thesuspicion of a thoracoabdominal wound, or the cardiac wound was found in thecourse of traumatic thoracotomy or during debridement of a large sucking wound,or it was searched for because of continued intrathoracic bleeding during thecourse of presumably adequate resuscitation. In 15 of the 75 cases in the 2dAuxiliary Surgical Group series, the injury was discovered at post mortem. In afew cases, it was found, in retrospect, that the symptoms and signs recorded onthe chart should have aroused suspicion before operation or autopsy.
Symptoms and Signs
Symptoms and signs were divided into two groups, symptoms due to anoxia andsigns suggestive of cardiac dysfunction.
In this series, six patients were recorded as dyspneic, six as needingcontinuous oxygen, five as mentally confused or semistuporous, and three ascyanotic. Before these findings could be attributed to a cardiac wound, however,other causes of oxygen deficiency, such as hemorrhage, hemothorax, compressionpneumothorax, and extensive peritoneal contamination, had to be ruled out. Whenthese conditions had been eliminated and symptoms due to anoxia persisted out ofall proportion to visible thoracic damage, then there was justification forregarding them as due to a cardiac lesion.
Signs suggestive of cardiac dysfunction included persistent tachycardia (apulse of 120 or above) in eight cases, arrhythmia in seven cases (transientfibrillation in one and extrasystoles in six), bradycardia (a pulse below 65) intwo cases, an apical systolic murmur and a precordial friction rub in two caseseach, a paradoxical pulse in one case, and nausea and vomiting in one case.
Both precordial friction rubs were heard for the first time24 hours after injury; operation was delayed 3 days in one case and 5 days inthe other. Since a friction rub or splash was noted in eight additional casesafter operation, it was concluded that a certain length of time must elapseafter wounding before this sign appears. The explanation of this phenomenon isthe presence in the pericardium of air and fluid. It was seldom seen because, inmost instances, the pericardial fluid had drained into the pleural cavity beforesurgery.
53
The single instance of paradoxical pulse occurred in apatient with severe myocardial contusion, who died in the shock ward. Thepersistent nausea and vomiting noted in one case was uncommon in thoracic woundsand led to the suspicion of a thoracoabdominal wound. Whether or not it wascaused by the cardiac wound, it was associated with it and made for furtherdiagnostic difficulties.
A precordial crunch or click was occasionally heard,synchronous with the heartbeat. It was associated with mediastinal emphysema andwas not considered related to the cardiac trauma.
In retrospect, the most important diagnostic findings were considered to be:
1. A sustained pulse of 120 or more after restoration of satisfactoryarterial tension by adequate resuscitation.
2. Continued cyanosis after recovery from shock.
3. Dyspnea out of all proportion to the evident pulmonarypathology. In several patients with cardiac wounds in this series, oxygen hadbeen necessary in the clearing station because of severe dyspnea and cyanosis.
4. The necessity for the early and continuous use of oxygen. These clinicalfindings were, of course, in addition to:
a. The obvious presence of a precordial wound.
b. The projection of the course of a missile which might reasonably haveinvolved the heart.
In a number of instances, irregularities of cardiac rhythmwere not apparent; abnormal cardiac sounds were not heard; and there was anotable absence of significant symptoms and signs, or those present were sotrivial as to be misleading. Makins (1) had called attention to theseobservations in his account of cardiac injuries in World War I. Generallyspeaking, the safest plan was to suspect cardiac injury whenever a patientseemed generally washed out; had a sustained, rapid pulse with transientirregularities of rhythm; and had a persisting need for oxygen.
Adjunct Diagnostic Measures
Roentgenologic and fluoroscopic studies.-In 15 cases,there was roentgenologic evidence of the injury. In eight cases the films showeda foreign body in the region of the heart, and in four instances the object wastermed fuzzy or double-contoured. In five cases the cardiac shadow was alteredin size or shape. In two cases the object was thought to be in the region of theheart, but there was no definite proof. In localizing missiles within thecardiac shadow, it was necessary to use heavy penetration (fig. 13),accomplished by the bone technique or the use of the Potter-Bucky diaphragm. Amissile could be completely overlooked if the chest was examined with the usualexposure. The interpretation of roentgenologic enlargement of the heart was alsoopen to some question when roentgenograms were made shortly after injury, sincethere is usually no appreciable stretching of the pericardium when fluid firstappears in it.
54
Some cardiac injuries were not suspected until repeated X-ray studies in ageneral hospital, combined with fluoroscopy, revealed their presence.
The cardiac injury also might be suspected by plotting theprobable course of the missile, using the external wounds and fractured ribs aslandmarks. Diagnosis was accomplished, or suspicion was aroused, by use of thistechnique in 22 of the 75 cases in this series. On the other hand, it was easyto be misled concerning a cardiac wound if the foreign body happened to lie freein the pleural cavity.
55
FIGURE 13.-Continued. D. Fragment after removal.
The diagnostic results might have been better if fluoroscopy had beenemployed more frequently, since this method permitted observation of possiblemovement of the object and also made it possible to determine whether it wasincluded in the cardiac shadow in all projections. The cardiac outline wasvariously described as fuzzy, blurred, enlarged, or of water-bottle shape. Intwo cases in which the outline was described as blurred or fuzzy, operationrevealed hemorrhage within the pericardial membrane and in the areolar tissuesof the lower mediastinum.
56
Electrocardiography-Neither electrocardiograms nor orthodiagrams wereavailable in forward hospitals. Electrocardiograms were most helpful indetermining whether a penetrating wound of the chest had involved the heart(fig. 14), particularly when the thorax was not explored at all or wasincompletely explored at debridement. In numerous instances, these studiesprovided assurance that the myocardium had not suffered injury. In a few cases,progressive alterations in originally normal tracings indicated the necessityfor removal of retained foreign bodies.
The most striking abnormalities, as reported by Lt. Col. Edward F. Bland, MC,were observed in myocardial injuries and involved the T-waves and S-T intervals.The predominating pattern was the so-called anterior-apical type, with inversionof T1, T2,and T4 (fig. 15). In the posterior basal typeof injury, electrocardiograms were secured in only two cases; in both, there wasinversion of T2 and T3.Electrocardiograms with inverted T-waves in all four leads were obtained in fivepatients. In one of these cases, roentgenograms showed foreign bodies in boththe anterior and the posterior cardiac walls. There was no explanation in theother cases for the total T-wave type of inversion.
High-grade conduction defects were not observed in any instance. Two patientswith abnormal W-shaped QRS complexes of low voltage and inverted QRS complexesin lead four were thought to have sustained cardiac contusions. In one case, apersistent P-R interval of borderline significance (0.2 second) may have beennormal for this particular patient.
In some cases, in which there was roentgenologic proof of thepresence of the foreign body in the heart (figs. 16 and 17), electrocardiogramswere completely normal.
57
58
CARDIAC TAMPONADE
Hemorrhage into the restricted confines of the pericardial sac,with resulting cardiac tamponade, was the chief danger from a penetratingcardiac wound (fig. 18). Tamponade was, however, relatively infrequent incombat-incurred injuries, in contrast to its frequency in civilian cardiacinjuries. The explanation is clear: In civilian life, small weapons, such asknives, icepicks, and small-caliber bullets, are generally used. As a result,the wound is small, bleeding is slow, and tamponade can develop as a physicalpossibility. In combat-incurred injuries, the wounds are large because themissiles are large, and an outlet for drainage into the pleural cavity istherefore provided. In a few cases, pneumopericardium occurred (fig. 19),without tamponade.
Hemorrhage into the pericardial sac was usually from thecardiac chambers but might also come from a severed branch of the coronaryartery, from a pericardial vessel, or from the myocardium itself. The thickmuscular wall of the ventricles seemed to tolerate severe lacerations, and eventotal penetration, without serious bleeding if the coronary arteries, especiallyarteries with sizable arterial branches, were not involved. In contrast, evenslight tears of the thin-walled auricles were apt to be followed by tamponade,which could develop within the space of a few minutes and could be rapidly fatalif it was not promptly corrected. Most casualties in whom hemorrhage wassufficiently rapid to produce early tamponade probably did not live long enoughto reach a hospital.
59
Diagnosis
The diagnosis of cardiac tamponade was generally based on the followingfindings:
1. Lowered arterial pressure.-In Elkin's (3)series, this finding was present in all cases, and in 17 of the 23, the bloodpressure could not be recorded. In all the patients who recovered, the pressurerose immediately after release of the tamponade.
2. Increased venous pressure readings.-These readings, as Elkin (3)noted, are of both diagnostic and prognostic value. If the venous pressure is
60
high, the assumption is that the cardiac output is at leastsufficient to sustain life. If the venous pressure is low, or falling, theassumption is that the heart is failing and the cardiac output iscorrespondingly reduced. Three of Elkin's patients who presented this phenomenondied on the operating table or immediately after operation.
3. A quiet heart.-This finding was first described byBigger (4) and, if it is studied fluoroscopically, the demonstration ofdecreased cardiac pulsations will be found to be extremely useful in diagnosis.
4. Engorgement of the cervical veins.-This phenomenon,which was present in a number of cases of tamponade, could readily be explainedas the result of the inability of these veins to empty into the right auriclewhich was com-
61
pressed by the tamponade. When this finding was present, itwas pathognomic, since such other causes as congestive heart failure, pulmonaryembolism, and mediastinal emphysema were unlikely to be encountered under combatconditions. Absence of distended cervical veins, however, and even of adistended pericardial sac, did not necessarily exclude continued serioushemorrhage from a wounded myocardium. In one case in this series, in which therewas continued, vigorous hemorrhage from a myocardial laceration, operationperformed 10 hours after injury revealed that tamponade had been prevented bythe passage of blood through the pericardial rent into the pleural cavity.
There were 5 instances of tamponade in the 57 cases in which the injuriesinvolved the heart proper. Death occurred in two because the condition was notrecognized or suspected. These cases and another case in which survival occurredhave features of special interest:
Case Histories
Case l.-Thispatient was injured in the left chest, shoulder, and buttock by shell fragmentson 14 December 1944. He was not in evident shock and at a field hospital, hiscondition was listed as good. Breath sounds were diminished over the left chest.He was given 1,000 cc. of physiologic salt solution intravenously beforeoperation, which was performed 7 hours after injury. All wounds were debrided.An open pneumothorax was closed without exploration. Aspiration of a hemothoraxyielded 300 cc. of blood.
The patient's postoperative condition was good. The pulse waswithin normal range, the blood pressure was 90/60 mm. Hg, and there was fullrecovery from the anesthesia. Four hours later, he was turned in bed, at his ownrequest. Shortly afterwards, he was found dead. Post mortem showed thepericardium to be distended with 200 cc. of blood and the heart to beconstricted. A perforation of the superior portion of the pericardium on theleft side, about 1.5 cm in diameter, was occluded by a fibrinous exudate. Ametallic fragment 1.5 by 1 by 1 cm. was found in the pericardial cavity. In theright ventricle was a laceration 1.5 by 1 cm in length and 3 to 4 mm. in depth. Asmall branch of the right coronary artery was severed. Two small mural thrombiwere found in the right ventricular cavity beneath the laceration. The liver wasmoderately congested. The cause of death was obviously cardiac tamponade, whichhad not been suspected before the post mortem examination.
Comment-The operating surgeon,who witnessed the post mortem, expressed the opinion that this soldier's lifecould have been saved if (1) thoracotomy with control of the coronary bleedinghad been carried out, or (2) if there had been closer postoperative observationfor signs of developing tamponade, which could have been relieved by aspiration(fig. 20). It is possible that if tamponade had been relieved, hemorrhage mighthave ceased spontaneously. More likely, exposure and ligation of the severedartery would have been necessary.
Case 2-Thispatient was in poor condition when he was received in a field hospital aftersustaining a bullet wound of the right lower quadrant of the abdomen. The neckveins were swollen and the heart sounds were barely audible. Although cardiactamponade was suspected, no blood could be aspirated from the pericardium, androentgenograms failed to disclose a foreign body in or near the heart. Atoperation, 15 hours after injury, a tear in the colon was sutured, and a gutterwound of the liver was drained. Left thoracotomy was then performed. Thepericardium was distended with clotted blood. The heart was constricted, and itsenfeebled action soon ceased, despite vigorous efforts at
62
resuscitation. Autopsy, which was performed immediately,revealed a .30-caliber bullet lying in the right ventricular cavity, surroundedby a foul-smelling clot. The bullet had been deflected upward from the pelvisand had passed through the colon and the liver before perforating the diaphragmand the right ventricular wall.
Comment.-A combination of unfortunate circumstances partly explained thefatal issue in this case. The negative results of two ordinarily reliableprecautionary measures served to disarm suspicion. One was the pericardial tap,which was dry because the blood was clotted. The other was roentgenologicfailure to demonstrate the missile within the thorax, probably because it wasobscured by cardiac motion. Under these circumstances, the swollen cervicalveins became extremely important from the diagnostic standpoint. They alwaysindicated serious circulatory imbalance which demanded correction before othersurgical procedures could be undertaken with safety. Whether or not thispatient's life could have been saved by initial thoracotomy is debatable, butthe fact that he survived 18 hours after wounding and withstood the added strainimposed by an extensive laparotomy before the chest was explored is highlysuggestive. Had the operative procedures been reversed, it might have beenpossible to relieve tamponade, check myocardial hemorrhage, and perhaps removethe intraventricular bullet. Even if its removal had proved impossible, it mighthave migrated later to the pulmonary artery without necessarily seriousconsequences, as in another case in this series (case 9, p. 82).
Case 3.-This patient sustained a penetratingshell-fragment wound of the left lumbar region, with a fracture of the tenthrib, on 8 July 1944. He was received at the field hospital in moderate shock,with a blood pressure of 90/50 mm. Hg. At operation, 8 hours after injury, asegment of the ninth rib was resected, and 1,400 cc. of blood was evacuated fromthe pleural cavity. A hole in the pericardium 2.5 centimeters in diameter wasextended to reveal a laceration of the same extent in the left ventricle, fromwhich a small stream
63
of blood exuded with each heartbeat. The hemorrhage wascontrolled and the laceration closed by two figure-of-eight silk sutures in theventricular wall. The pericardium was left open for a distance of 6 centimeters.The foreign body was found in the lower lobe of the left lung, with a hematomabut no hemorrhage. When the diaphragm was opened between the anterior and theposterior perforations, the spleen was found fractured and actively bleeding. Itwas removed. Two perforations of the stomach were sutured. The diaphragm and thechest wall were then closed.
The patient's immediate postoperative condition was good, the blood pressurebeing 110/70 mm. Hg. Ten days later, his condition was still good; he had nocomplaints, and temperature, pulse, and respiration were normal. There was nofluid in the pleura, but a pericardial friction rub was noted. The followingday, the patient was transferred to a general hospital. On 23 July, he suddenlycomplained of severe dyspnea and precordial pain and became extremely cyanotic.The lungs were filled with rales. The pulse was 130. Gradual improvementoccurred following the administration of morphine and oxygen, and 4 hours later,the lungs had cleared. The medical consultant made a diagnosis of acute leftventricular failure.
The following day, an electrocardiogram showed late inversionof T1 and T4, with low voltage of the QRS complexes,consistent with recent left ventricular injury and probably pericarditis. By 25July, the patient was much improved; the heart sounds were good, and he had nocardiac symptoms. Electrocardiograms on 8 August and on 21 August were stillabnormal, but the inversion of the T-waves was less marked. On 11 September, 8weeks after injury, he was evacuated to the Zone of Interior in good condition.
Comment-This case is of special interest on two counts: (1) In spite ofserious injury to the heart, lungs, stomach, and spleen, this patient survived.His convalescence was undoubtedly hastened by early and adequate surgery. (2)This is the only case in the entire series of cardiac injuries in which delayedacute left ventricular failure occurred (on the 15th day). The preciseexplanation for this isolated and unexpected episode remains obscure. In thiscase, as in several others, cardiac tamponade was prevented by the escape ofblood through a sizable pericardial rent. It is probable that the cardiachemorrhage accounted for the major portion of the 1,400 cc. of blood evacuatedfrom the left chest at operation.
PATHOLOGIC PROCESS
Cardiac injuries encountered at surgery or autopsy were classified ascontusions, lacerations, lacerations and contusions, penetrating wounds of thecardiac chambers with retained foreign bodies, and perforating(through-and-through) wounds. Cardiac emboli were also possibilities. Theseinjuries were additionally classified according to the particular cardiacstructure involved.
Superficial abrasions of the epicardium and engorgement or thrombosis of thesubepicardial vessels were often found. When a major artery was badly contused,thrombosis was a possibility.
The myocardium might show gross evidence of degeneration or actual necrosis.Microscopically, interstitial hemorrhage varied in variety and extent. Themuscle fibers showed fragmentation, loss of striation, or advanced necrosis.Eosinophilia, leukocytic infiltration, and beginning phagocytic removal ofnecrotic muscle tissue were observed as early as 18 hours after injury.
When the endocardium was injured or there was subendocardial hemorrhage,adherent mural thrombi might develop. This was observed in five cases
64
in this series, in three instances at autopsy. When extensivelesions were scattered along the acute or the obtuse margins of the heart, thehemorrhage might involve the myocardium of both ventricles and extend into theinterventricular septum.
The high rate of energy imparted to the tissues in the track of the missileexplained why particles of tissue were thrown laterally and passed their energyon, thus producing further damage. Attention has already been called to thecases in which fragments of the ribs produced this sequence of events, which wasespecially likely to occur in tangential wounds.
In some instances, the missile passed through the myocardium at such an anglethat the cardiac walls closed behind it.
PERICARDIAL INJURIES
General Considerations
There were 18 instances of pure pericardial injury in this series, with 3deaths, all of which occurred more than 48 hours after wounding and none ofwhich was due primarily to the pericardial injury. In 14 instances, the woundswere lacerated; and in 5, foreign bodies were present, in 2 instances consistingof rib fragments. One of these missiles was in the free sac.
In one case, injury of the pericardium was associated with aninjury of the myocardium; it is quite remarkable that this combination ofinjuries did not occur more often, as some of the pericardial lacerations weresevere. It is also quite possible that minor lacerations of the pericardiumoccurred and remained undetected. The academic question also arises as to theprobable considerable margin of safety afforded by a heart in systole ascompared with one in diastole at the moment of injury (Wood (5) andNicholson's "near misses").
Management
The mere diagnosis of cardiac tamponade was not regarded as an absoluteindication for surgical intervention. In several cases, prompt recovery followedpericardial aspiration alone (fig. 20), sometimes after a single aspiration. Thegeneral opinion, however, was that it was hazardous to depend routinely uponthis type of conservative management, especially if an irregular foreign bodywith sharp margins or points was demonstrated in either the myocardium orpericardium. Under the circumstances, if more than two satisfactory aspirationswere necessary, it was considered that surgery was indicated. The possibility ofinfection also had to be considered (p. 356).
In urgent cases, management consisted of repeated aspirationof the pericardium until surgery could be undertaken. The needle was inserted inthe angle between the xiphoid process and the adjacent left costal arch and wasdirected cephalad, inward, and toward the left, at an angle of about 45?.
65
Repair was accomplished through a curved incision exposingthe third, fourth, and fifth costal cartilages; resection of sufficient portionsof these ribs to exposed the pericardium; incision of the pericardium; andsuture of the wound by the technique recommended by Elkin (3) and by Beck(6).
In 5 of the 18 pericardial injuries, the pericardium wassutured tightly. In the remaining cases, drainage was instituted into thepleural cavity. In two of these five cases, in one of which there was anassociated myocardial wound, there was massive, troublesome pericardial effusionpostoperatively, a complication not observed in any case that was drained.Recovery in both cases followed paracentesis. All five foreign bodies wereremoved. In two other cases, in which it was thought that foreign bodies mightbe present in the pericardium, no attempt was made to remove them.
In one case, the pericardial sac was enormously distended with blood. It wasincised for a distance of 10 cm. from the superior to the inferior margin, andthere was no further bleeding after the first gush of blood. The pericardium wasleft open and the chest was closed. Recovery was uneventful. The origin of thetamponade in this instance was obscure, but the azygos vein, although it isusually extrapericardial and therefore an unusual source of intrapericardialhemorrhage, was considered the most probable source.
Pneumopericardium was observed in three of the pericardial injuries, as theresult of the entrance of air into the pericardial sac from a pneumothorax,injured lung, bronchus, or esophagus. In two cases, the air was promptlyabsorbed, without evidence of pericardial irritation. In the other case, fibrouspericarditis developed.
While a pericardial wound was sometimes relatively innocuous,at least as compared to the lethal potentialities of other cardiac wounds, itcould be extremely urgent. This is clear if the pathologic process (fig. 18) beconsidered: With fluid in the pericardium, an obstruction exists to the fillingof the heart, and the blood is dammed up in the great venous channels of thebody. If the intrapericardial pressure comes to equal the effective venouspressure, the blood can no longer enter the right auricle and death will occurpromptly. That is why so many deaths from this cause must be assumed to haveoccurred on the battlefield and why, in some instances, the condition might beso urgent that the time required to confirm a suspected diagnosis byroentgenologic or fluoroscopic examination might mean the difference betweenlife and death.
CONTUSIONS
General Considerations
The 16 contusions observed in the 2d Auxiliary Surgical Groupseries of cardiac wounds were similar to the contusions described by Elkin (3),Beck (6), and others in civilian life, as the result of blunt trauma tothe chest, steering wheel injuries, and similar accidents.
66
There were 11 deaths in the 16 cases, in 6 of which the cardiac state wasconsidered entirely responsible for the fatal outcome.
The diagnosis of a cardiac contusion was not particularlydifficult. Most of the patients with significant injuries of this type presentedsigns and symptoms indicative of oxygen want and cardiac dysfunction, that is,tachycardia and arrhythmia. These signs and symptoms, as well as the gross andmicroscopic appearance of the myocardium at autopsy, had much in common with theclinical and pathological picture of myocardial infarction following coronaryocclusion.
Pathogenesis and Pathologic Process
In most of the battle casualties, the damage resulted fromthe force propagated by the passage of a small, high-velocity missile in theimmediate vicinity of the heart. In at least one instance of myocardialcontusion (fig. 11), the ribs were shattered, and their fragments apparentlyacted as secondary missiles, with resultant direct blunt injury. Thrombusformation followed, and death ensued; the pericardium was intact.
Whether a localized blast effect resulted from the passage ofthe missiles in these cases cannot be answered. Certainly, in this series, nocardiac contusion resulted from the generalized effect of a pressure wave in theatmosphere. While it was theoretically possible for a serious cardiac injury toresult from blast, there was no confirmation at autopsy, in which thepossibility was borne in mind in the examination of patients who died of blastinjuries.
Clinical and experimental studies before the war hadclarified the pathologic physiology of thoracic contusions. Bright and Beck (7),as well as Warburg (8), had demonstrated that trauma to the intact chest,especially in the young adult whose chest is far more resilient and flexiblethan the chest of an older person, may be directly transmitted to the heart,whether the injury is a direct blow over the precordial region, compression ofthe chest between two solid objects, or a blow over the abdomen, with a suddenrise in intra-abdominal pressure.
Experimental trauma most often caused immediate rupture of one of the cardiacchambers, with death. Contusion, with resultant petechial hemorrhage, softeningand necrosis of tissue, and eventual rupture, might involve any portion of theconduction system. Most frequently, it caused reflex spasm of the coronaryvessels, with the production of a syndrome like the common civilian-typesyndrome of coronary occlusion and infarction. It was also shown experimentallythat in cases of vagosympathetic imbalance, or when the heart was sensitized byadrenalin, cardiac irregularities and coronary spasm resulted more readily. Inthe heat of battle, when the vascular system was surcharged with considerableadrenalin, slight trauma to the chest might conceivably cause considerablecardiac disturbance.
The pathologic process in contusive lesions consisted ofscattered or confluent petechial hemorrhages involving the myocardium overvarious areas of one or both chambers (fig. 21). In these 16 cases, theventricles were involved
67
15 times (7 left, 5 right, 3 both) and the right auricle,once. Superficial abrasions of the epicardium and engorgement of thesubepicardial vessels were sometimes observed. The myocardial hemorrhage oftenextended through to the endocardium, and the muscles sometimes showed grossevidence of degenerative changes or actual necrosis. In fatal cases, in whichthere had been involvement of the entire thickness of the myocardium, muralthrombi were frequently found attached to the endocardium (fig. 11). Whenextensive lesions were scattered along either the acute or the obtuse cardiacmargin, it was not uncommon to find hemorrhages extending into the myocardium ofboth ventricles, and even into part of the interventricular septum. Thepericardium was not necessarily injured in myocardial contusion; it was intactin 9 of the 16 cases in this series. The pathologic pattern in the fatal caseswas essentially one of subpericardial and subendocardial hemorrhage, usuallypetechial in distribution.
Management
A patient with a myocardial contusion was a poor risk for anykind of surgery, especially during the first several hours after wounding. Thefact that 6 of the 11 deaths in these 16 cases were due to the cardiac lesionindicates just how poor risks these casualties were.
68
The contusion itself was not a surgical lesion, but, unfortunately, numerousassociated wounds often required that surgery be done promptly. Ideally, it waspostponed for 24 to 48 hours, but this was frequently impossible. Certainwounds, such as thoracoabdominal wounds, required prompt operation, in spite ofthe fact that immediately after injury, the risk of death from irritability ofthe myocardium and potentially lethal arrhythmias might be entranced byanesthesia or surgical manipulations. The best that could be done was to delaysurgery as long as possible, to permit some degree of cardiac recovery.
In the meantime, the patient was treated as if he were suffering from acutecoronary occlusion. Resuscitation was carried out, and surgery was thenundertaken with due realization that the risk was inevitably great and themortality would be correspondingly high. In purely thoracic wounds, in whichsurgery was not mandatory within 6 to 12 hours, it was best to delay it as longas possible.
In three fatal cases in this series, in which operation was performed,respectively, at 5, 11, and 17 hours after wounding, it was thought that furtherdelay might have been beneficial. Two of the wounds were purely thoracic. Theother was a high thoracoabdominal wound, in which it was clear that only theliver was involved. In each instance, signs of cardiac dysfunction wereprominent. During resuscitation, the patients were in poor general condition,semistuporous, with rapid pulse, and dyspneic out of all proportion to thevisible intrathoracic damage. In each instance, the systolic pressure waselevated to 95 mm. Hg or higher, but death occurred on the operating table orimmediately after surgery was concluded.
In another case of this kind, not included in this series, the timelag wasonly 6 hours. Death occurred on the operating table. At autopsy, it wasconfirmed that the wound was purely thoracic. There was extensive contusion ofthe right ventricle and thrombosis of the anterior descending branch of the leftcoronary artery.
Any of these patients might well have died, even if surgery had not beendone, but the added burden of the anesthetic and the operative procedures cannotbe ignored in assessing the outcome in seriously wounded patients.
In two other cases in this series, which may be cited incontrast, surgery was delayed for 3 and 5 days, respectively, after wounding.Both patients were received in shock. In one case, the pulse remained over 120for 48 hours. In the other, for 4 days, there were intermittent periods ofcardiac arrhythmia, associated with wet lung, pulmonary edema, and jaundice. Ineach instance, the surgeon expressed the opinion that the patient might wellhave died if operation had been done even as late as 12 hours after wounding.
The final conclusion was that if a cardiac contusion were diagnosed and suchindications for early surgery as continuing hemorrhage or a thoracoabdominalwound did not exist, surgery should be deferred for at least 24 to 48 hours, toprovide every opportunity for the reduction of myocardial irritability.
69
Electrocardiograms in two survivors of contused wounds wereidentical with respect to (1) abnormal W-shaped QRS complexes of low voltage inthe limb leads and (2) inverted QRS-4 (fig. 22). This pattern was not observedin any other type of cardiac injury. These electrocardiograms also showed theabnormalities of T-waves and S-T intervals frequently seen after myocardialinjury.
LACERATIONS
General Considerations
Of the 20 lacerations in this series, 10 were combined withcontusions of the myocardium and 4 were detected only at post mortem. In the 10pure lacerations, the left ventricle was affected in 7 cases, the rightventricle in 2, and the right auricle in 1. These 10 cases, in 2 of which therewere foreign bodies in the myocardium, comprise all the instances in the seriesof incised, cleanly lacerated wounds of the myocardium in which there was nogross evidence of myocardial contusion or necrosis.
In the combined lacerations and contusions, the left ventricle was affectedfive times, the right ventricle twice, and both ventricles twice. In the remain-
70
ing case, the right auricle and right ventricle were injured.The serious implications of contusions are again evident in this group, in whichthere were five deaths, four due to the cardiac wound, against the single deathdue to a cardiac lesion in the pure lacerations.
Management
An analysis of the records shows that a rather surprising number-10-of the 16lacerations of the myocardium were not repaired, and apparently with noimmediate ill effects. In the four lacerations found only at post mortem, therewas no evidence in any instance that the fatality was due to failure to effect arepair.
In the six cases which were repaired, the laceration wascompletely closed in four by suture. In the two other cases, completeapproximation was impossible, and the pericardium was used to help bridge thedefect; free muscle grafts were also used (figs. 23 and 24).
71
The pericardium was either sutured over the wound or sutured to the edges ofthe poorly approximated wound. In the former instance, posterior drainage wasemployed.
The number of cases is too small to permit drawing any conclusions as to thewisdom of operating in forward hospitals solely to suture cardiac lacerations.
PENETRATING AND PERFORATING WOUNDS
General Considerations
There were 19 instances of perforating or penetrating woundsof the heart in this series, 7 involving the left ventricle, 3 the rightventricle, 2 the left auricle, and 7 the right auricle. There were nine deaths,in eight instances due to the cardiac lesion. In one wound of the auricle,discovered only at post mortem, death occurred 24 hours after wounding. In theopinion of those who witnessed the autopsy, the fatal outcome was due toextensive wounds elsewhere in the body. It was thought that the patient wouldhave survived without auricular repair. The most frequent complication, and themost important cause of death, was hemorrhage, which could readily beexsanguinating.
72
It is of great interest that through-and-through cardiacwounds were not always immediately fatal. In one case in this series (p. 75),recovery followed the repair of two wounds of the left ventricle caused by ashell fragment that divided the left phrenic nerve and the pericardiophrenicvessels, entered the left ventricle at the apex, and made its exit on theposterior wall. Operation was performed 14 hours after wounding.
One other patient with a through-and-through wound of the left ventricle alsosurvived. The three perforations of the right auricle all ended fatally. In theexperience of the 2d Auxiliary Surgical Group, no patient with a perforation ofthe interauricular or interventricular septum survived to reach a forwardhospital.
Management
The chief indication for immediate surgery in wounds of thecardiac chambers was continuing hemorrhage. If bleeding caused tamponade ratherthan exsanguinating hemorrhage, as it sometimes did, treatment could be moreindividualized. If the tamponade developed rapidly, it was considered better tooperate at once, particularly if it was known that the missile causing the woundwas large. If the tamponade developed slowly, one or two aspirations might beattempted (p. 64).
If foreign bodies were encountered in the course of theoperation, an attempt was made to remove them. If their presence was suspected,an attempt was made to locate them. If, however, they were not foundimmediately, the correct procedure was to control the hemorrhage and close thechest. Since hemorrhage was the indication for operation, a long-continuedsearch for the missile, with blind manipulations within the cardiac chambers,could not be considered justified. The foreign body could be removed later atthe base hospital if that proved necessary.
Complete closure of the cardiac wound was possible in 10 cases. One wound hadceased to bleed when it was exposed, and suture was not considered necessary. Intwo instances, both auricular wounds, attempts at closure failed, and bothpatients died of intractable hemorrhage. Attempts to plug the defect with thefinger were unsuccessful.
Case Histories
Case 4.-This 22-year-old private was wounded by an artillery shellfragment on 27 June 1944. At the field hospital, 2 hours later, he was found tobe mildly shocked, but he was conscious and in fairly good condition.Examination revealed a lacerated wound, 3 cm. long, in the fifth leftintercostal space, just outside the midclavicular line. There was no dyspnea orhemoptysis. The heart tones were normal, and no adventitious sounds were heard.There were signs of fluid in the left pleural cavity. The abdomen was tender andresistant to pressure.
The patient became nauseated and vomited twice shortly afteradmission. A Levin tube was passed into the stomach, and 250 cc. of air andfluid were withdrawn; there was no blood in the gastric contents.
73
74
After 500 cc. of plasma and 1,000 cc. of blood had been givenover a 2?-hour period, the blood pressure rose from80/60 to 130/70 mm. Hg, and the pulse fell from 110 to 90. Abdominal signs andsymptoms persisted. Roentgenologic examination (fig. 25A) showed the shellfragment lying well posterior, apparently just within the costal cage. From thelocation of the wound, the apparent course of the missile, and the persistingabdominal signs, especially the nausea and vomiting, a thoracoabdominal woundcould not be ruled out.
Operation was carried out under endotracheal anesthesia 6 hours afterwounding and 3? hours after hospitalization. Bloodtransfusion was continued during the procedure.
75
After debridement, anterior thoracotomy was performed in the fifthintercostal space by extension of the wound of entrance. A chip fracture of thefifth rib was found, with a small contusion of the lingula of the left upperlobe, but the diaphragm was intact. Five hundred cubic centimeters of blood wereevacuated from the pleural cavity, after which the shell fragment was discoveredlying free posteriorly. Two perforations were seen in the pericardium. Thepericardiophrenic artery and phrenic nerve had been severed anterolaterally(fig. 25B), and a posterior laceration was found just lateral to the reflectionof the parietal pleura from the pericardium onto the mediastinum. Thepericardial sac was opened by vertical incision a few minutes after 5 cc. ofprocaine hydrochloride had been injected into it. Two lacerated wounds of theleft ventricle, each 8 mm. in length, were found oozing blood with each systole.The wound of entrance was at the apex and the wound of exit in the midportion ofthe left ventricular wall posteriorly (fig. 25B).
The apex of the heart was rotated 90? forward and steadied by the right handof the assistant (fig. 25C). The wound was exposed between the spread of hissecond and third fingers, and bleeding was controlled by the application of twosilk sutures (No. 0). A small venous branch was occluded by the sutures.
The anterior laceration was irregular, and the muscle gaped slightly. Oozingcontinued, particularly after a suture had cut partly through the muscle. It wascontrolled by suturing a small pedicled graft of anterior pericardium andpericardial fat over the laceration (fig. 25D).
Extrasystoles were numerous while the heart was manipulated but ceasedimmediately when manipulations were discontinued. Crystalline sulfanilamide andpenicillin were placed in the pleural cavity, and drainage was instituted bymeans of two water-trap tubes. A small mushroom catheter was used in the secondintercostal space anteriorly
76
and a quarter-inch fenestrated tube in the eighth intercostalspace in the midaxillary line. The tube was clamped off for 8 hours afteroperation, to permit contact of the chemotherapeutic agents with the tissues.The incision was closed in layers, without pericostal sutures.
At the conclusion of the operation, the blood pressure was 110/70 mm. Hg. thepulse 145, and the respiration 32. Standard postoperative measures wereemployed. Recovery was generally smooth. The blood pressure remained normal; thepulse stabilized at 100-110. Cardiac irregularities were never evident.
Twenty-four hours after operation, a splash, synchronous with systole, washeard over the precordium. Four days later, a loud precordial friction rub wasaudible for 24 hours; during the same time, the second sound in the pulmonicarea was occasionally reduplicated. On the sixth day, there was a slightroughening of the first sound at the apex, and a poorly transmitted, softsystolic murmur was heard in this area.
When the patient was transferred to a general hospital on the 12thpostoperative day, he was afebrile, with a pulse of 88 and a blood pressure of115/60 mm. Hg. He became ambulatory in another week. A scratching to-and-froprecordial friction rub was heard intermittently for another 2 weeks.
Roentgenologic examination 8 weeks after operation showed the lung fieldsclear and the heart normal in size (fig. 25E). Electrocardiograms 2 weeks afteroperation showed moderate inversion of T-waves with elevated S-T intervals inthe first three leads and moderate left axis deviation (fig. 26). Two weekslater there was less inversion of T1. Another electrocardiogram 2weeks after the first showed T1 upright, but T2 and T3remained deeply inverted, and left axis deviation persisted.
No signs of cardiac embarrassment developed as the patient increased hisactivities, and he was in excellent condition when he was evacuated to the Zoneof Interior 11 weeks after injury.
Comment-This case is remarkable because, in spite of thethrough-and-through wound of the heart, the patient survived, after early,adequate surgery. Convalescence was quite smooth. It is noteworthy that in spiteof the double wound in the ventricle, the blood loss was minimal. It is alsonoteworthy that no signs of cardiac weakness ensued in spite of the multiplewounds elsewhere, plus the necessary manipulation of the heart at operation andthe repeated intravenous infusions of blood and saline solution that werenecessary.
The serial electrocardiograms available in this case were thought to be thefirst on record taken during recovery from a complete perforation of the heart.It is of some interest that the effect of the T-waves in leads II and III of theposterior (basal) injury appears to have overshadowed the effect of the apicalwounds (leads I and II), possibly because of the greater mass of muscle injuredin the penetration of the thicker basal wall of the ventricle.
That this patient survived his original wound seems due to a happy andunusual chain of circumstances. The fragment must have struck end-on and passedthrough the heart without revolving. It also seems probable that the perforationoccurred during diastole, so that the chamber was traversed by the missilewithout irreparable damage to the papillary muscle.
As this case also demonstrates, there may be few if anylocalizing signs or symptoms in spite of a serious cardiac wound. The nausea andvomiting were probably cardiac in origin; these symptoms do not usually occur inpure thoracic injuries. With the shell fragment free in the pleural cavity, thecourse of the missile was misleading, and the wrong conclusions concerning itwere drawn. Had the missile come directly from the front, it could not havefailed to penetrate the diaphragm. It came, however, from the left, passedthrough the heart, and then fell free in the pleural cavity, almost opposite thewound of entrance in an anteroposterior plane.
77
FIGURE 26 (case 4).-Repair of through-andthrough wound of heart. Serial electrocardiograms 12 days, 17 days, 41 days, and56 days after wounding. Note that residual inversion of T2and T3 overshadows thetemporary inversion of T1(T2) pattern ofanteriorapical injury.
78
Case 5-In another ventricular injury, the patient diedin the shock ward of a field hospital 6 hours after he had received apenetrating wound of the left chest, before operation could be performed.Autopsy revealed that a single shell fragment, 1 by 1 by 1 cm., had entered thechest through the left scapula, fractured the third and fourth ribs posteriorly,and then perforated the wall of the left ventricle, to become embedded in theopposite ventricular wall. Death was caused by hemorrhage from the heart intothe left chest. The rent in the pericardium had permitted the escape of bloodand thus prevented tamponade.
Comment-The comment of the medical officer who performedthe autopsy was that this man had lived for 6 hours with a hole in his heart andthat his life might have been saved if adequate blood had been available and ifthe chest had been opened at once.
MIGRATORY FOREIGN BODIES
General Considerations
The intravascular migration of projectiles and other foreign bodies to theheart and pulmonary circulation from distant wounds by way of the great veins isso uncommon as to constitute a true medical curiosity.1 Althoughstill rare, these migratory objects were recognized more frequently in World WarII than in the past. The need for their removal was still the subject of somedisagreement. Some objects remained asymptomatic for long periods of time, butothers, because they served as foci of infection or caused damage to themyocardium, caused death from embolism. Early removal in a base section centerwas considered the wisest plan if cardiac disability or other clinical signs andsymptoms were present. Otherwise, the policy was to return the patients to theZone of Interior.
If the fragment entered the pulmonary circulation from theright heart, it was theoretically possible for it to serve immediately as afatal embolus. Removal of a missile from the pulmonary vessels could be attendedwith great difficulty and might require the sacrifice of an essential artery,perhaps with lobectomy or pneumonectomy. In one case in the 2d AuxiliarySurgical Group experience, surgery was not carried out for this reason (case 9,p. 82).
Migratory foreign bodies were not necessarily fatal. Three of five patientsobserved in the Mediterranean theater are known to have recovered, and at leastone of the two deaths was not caused by the presence of the foreign body, whilethe same comment is possibly applicable to the other case. The case historiesfollow.
Case Histories
Case 6-A soldier who sustained a penetrating shell-fragment wound of theright cervical region on 17 June 1944 was treated conservatively. Roentgenogramsrevealed a
1Although only one instance of migratory foreign body seems to havebeen reported in World War I (9), undoubtedly others occurred. In thereported case, a shell fragment buried in the liver was left in situ atoperation. The patient died of peritonitis 6 days later. At necropsy, the metalfragment was found covered with fibrin and enmeshed in the columnae carneae.Examination of the liver disclosed the track of the fragment into its point ofentry into a large hepatic vein and its subsequent intravascular passage to theheart.
79
foreign body in the right mid lung field, with no evidence ofpulmonary injury. He was discharged to duty on 21 July but on 9 August wasreadmitted to the hospital, complaining of dyspnea and a vague pain in the rightchest on effort. Roentgenograms showed the foreign body in the same position asat the first examination. At exploratory thoracotomy on 18 August, the missilewas found in the right inferior branch of the pulmonary artery. It was palpatedthrough the wall of the artery but was not removed. On 10 October, when thepatient was evacuated to the Zone of Interior, he was ambulatory but was stillmildly dyspneic, and he continued to complain of vague chest pains on effort.
Comment.-When this patient was first admitted to thehospital, it was thought that the missile had entered the thorax directly fromthe cervical wound. In the light of the findings at operation, however, it mustbe assumed that it penetrated the right subclavian vein, migrated to the rightside of the heart, and thence passed to the right pulmonary artery. Noinfarction resulted, and it was considered unlikely that it would cause serioustrouble at its present site.2
Case 7-This man sustained penetrating wounds of the right flank on 11October 1944, with a resulting perforation of the colon and another of the leftchest, with hemothorax.
2As already pointed out (p. 17 fn), postwarexperimental studies by Dr. Lyman A. Brewer III and his associates showed thatmetallic foreign bodies in the lobar branches of the pulmonary artery areusually well tolerated, provided that the bronchial arteries remain intact.Those occluding the main pulmonary arteries cause serious pulmonary changes andshould be removed.
80
The following day, laparotomy and colostomy were performed, and the chestwound was closed. On 25 October, he died from an intraperitoneal hemorrhage.Necropsy revealed multiple penetrating wounds, including a puncture wound, 0.8cm. in diameter and surrounded by necrotic tissue, on the posterior wall of theinferior vena cava just above its formation. An embolic shell fragment 1.5 by0.6 by 0.4 cm. was found in the inferior branch of the left pulmonary artery,with no evidence that it had entered through the lung parenchyma (fig. 27).There was no associated pulmonary infarction. The anatomic cause of death wasmassive hemorrhage secondary to the abdominal wound.
Comment-The metallic embolus to the lung found in this case at autopsywas a complete surprise. There had been no signs or symptoms suggestive of itspresence before death, and roentgenologic study had not seemed justified becauseof the patient's continued precarious state. It is entirely probable that hewould have recovered from the vascular injury had he not succumbed, 2 weeksafter wounding, to the secondary complications of his severe abdominal injuries.
Case 8-This patient sustained penetrating wounds of the right shoulderand the right lumbar region on 2 October 1944. Though laparotomy revealed that aforeign body had entered the abdomen, it could not be found. Subsequentroentgenograms suggested that it was on the right side and lying in the psoasmuscle. On 7 October, the roentgenograms were repeated because the patient hadcontinued to run fever and had developed rales on the left side. The film washazy, and the foreign body seen in the first film on the right side now appearedto be above the diaphragm on the left side.
Two days later, the temperature rose to 104? F. Otherfindings included a rapid pulse (from 140 to 160); a blood pressure of 95/50 mm.Hg; a variable systolic sound of unusual character over the heart to the left ofthe lower sternum, somewhat suggestive of a friction rub; and pulmonary rales.There was no venous distention. Roentgenograms revealed the foreign bodyapparently lying anteriorly and inferiorly in the pericardium and slightlyblurred by motion. On 12 October, the patient continued to have fever, pulmonaryrales were still present, and the superficial systolic "noise"persisted. His condition deteriorated progressively, and he died before adefinite diagnosis was made, though the pyrexia was thought to be due tomalaria.
At autopsy, when a penetrating wound in the right flank was explored, a trackwas found which indicated that the foreign body had entered the inferior venacava. Continued exploration revealed it lying free in the right ventricle (fig.28A). The entrance of the missile into the inferior vena cava was represented byan oval defect 1.5 by 1.5 by 5 cm. in the posterior wall above the bifurcation(fig. 28B). The defect was surrounded by numerous thrombi, some of whichappeared to have become detached. The fragment found in the right ventricle nearthe apex was large and irregularly oblong. It measured 2.3 by 1 cm. and weighed10.35 grams. There was slight discoloration of the adjacent endocardium, but nothrombi were found. Careful examination of the heart and vena cava revealed noevidence of penetration, and there was no doubt that the metal fragment hadentered the vascular system through the wound in the lower vena cava. Both lungsshowed widespread areas of infarction, and multiple emboli were demonstrable inthe pulmonary arterial branches. In addition, there was massive intraperitonealhemorrhage (1,500 cc.) from an omental vessel.
Comment-In spite of the size and weight of this jaggedfragment, it had apparently churned about in the right ventricle for over a weekwithout causing serious injury to the cardiac wall. Although it was apparentlytoo large to pass through the pulmonary orifice, at no time did the patientexhibit acute seizures suggesting a ball-valve effect, and at no time were thecervical veins distended. The persistent fever and downhill course wereadequately explained by the recurrent pulmonary emboli from the mural thrombi inthe lower vena cava, but these phenomena were probably unrelated to the presenceof the foreign body in the right ventricular cavity.
81
82
Case 9-When this soldier was wounded in action on 12April 1944, he sustained multiple severe penetrating wounds of the right thorax,right leg, and both feet. Initial roentgenologic study showed a large metallicforeign body in the left lung. The wounds were debrided.
On 28 April, when he was transferred to a thoracic surgery center, hiscondition was good except for moderate dyspnea, which continued aftercardiorespiratory disequilibrium had been treated by adequate thoracentesis andnerve block. Localization studies showed the fragment to be in the hilar regionof the left lung (fig. 29A and 29B). Fluoroscopy on 9 May showed it to be in theroot area on this side.
At thoracotomy the following day, the foreign body could notbe found, and the chest was finally closed after a long and fruitless search forit. Roentgenograms taken immediately after operation revealed it lying in theright hilar region (fig. 29C).
83
After operation, the patient remained more dyspneic thanseemed warranted by the findings in the chest. The only change noted onelectrocardiography was a moderate sinus tachycardia.
On 9 July, a right-sided thoracotomy was done, after repeatedroentgenograms and fluoroscopy immediately before operation had shown thefragment still in the right hilar region (fig. 29D). The missile was foundimpacted within the lumen of the main right pulmonary artery. A palpable thrillwas felt over it and for a short distance into the artery distally. Thepulmonary circulation was entirely adequate. Complete dissection of the hilarstructures did not achieve sufficient mobilization of the artery to warrant an
84
attempt to remove the missile, since the involved segment ofthe artery lay directly beneath the superior pulmonary vein anteriorly and uponthe right stem bronchus posteriorly. Since there was no evidence of aneurysmaldilatation of the artery or of inadequacy of the pulmonary circulation, it wasdecided not to sacrifice the posterior pulmonary vein in order to remove theforeign body.
Convalescence was uneventful except for a disproportionate degree of dyspneafor a few days following operation. The patient was transferred to the Zone ofInterior on 16 August, ambulant and in good condition. In October, a followupletter from the United States reported that he had continued well, with nosymptoms other than dyspnea when he walked rapidly. No further roentgenologicstudies and no operative procedure had been carried out.
Comment-This case might be fairly termed unique in medical annals. Theopportunity for adequate roentgenologic study and for complete exploration ofboth hilar regions by a competent chest surgeon left no doubt that the largemetal fragment had migrated, against the blood flow in the pulmonary circuit,from its original position in the left pulmonary artery to its subsequentlodgment in the right pulmonary artery, without causing serious symptoms orrecognizable complications. The exact mechanism of the migration is difficult toexplain. It seems unlikely that it was accomplished by gravity alone. It mayhave been the result of manipulation during the exploration of the left hilarregion, but no definite statement can be made on this point.
It is a matter of special interest that during a review of this case shortlyafter the first thoracotomy, the operating surgeon stated that the missile hadprobably entered a major lobar radicle of the right pulmonary artery and hadprogressed from there.3
Case 10-This patient sustained a machinegun bullet woundwhich penetrated the right chest, just below the middle third of the clavicle,on 31 May 1944. On 4 June, he was transferred from a field hospital to a generalhospital. He was then in fair condition except that his temperature was 102?F., the heart sounds were distant, and the veins of the neck were distended.Roentgenograms showed an enlargement of the heart shadow and a foreign body 1.7by 1 cm. inside the left cardiac border. In the right chest was a moderatecollection of fluid. On 7 June 1944, there was considerably increased distentionof the neck veins, and the venous pressure was 210 mm. H2O.Electrocardiograms showed QRS complexes of low voltage. Pericardicentesisproduced 750 cc. of old, bloody fluid. The patient showed prompt improvement buthad a pericardial friction rub for the next 3 days. Roentgenograms showed asmaller heart shadow, together with a surprising shift of the foreign body,which now lay just inside the right border of the heart. By 20 June, the patientwas ambulatory. His improvement was progressive and satisfactory except that hecomplained of a dull pain running from the sternum to the cardiac apex when hewalked. Roentgenograms showed the foreign body now lying behind the cardiac apexjust inside the left border. On 2 August, the foreign body, which was embeddedin dense pericardial adhesions behind the apex, was removed, with considerabledifficulty. On 2 October, the patient was evacuated to the Zone of Interiorfully ambulatory and complaining only of slight substernal ache on effort.
STAB WOUNDS
The single stab wound in the series, which wasself-inflicted, was similar to the same type of injury observed in civilianpractice. Emergency surgery, 16 hours after injury, was required to controlhemorrhage from a small punc-
3This patient was seen again in 1948, at which time hewas perfectly well. In April 1959, he suffered profuse hemoptysis because theforeign body had eroded through the right pulmonary artery into the rightbronchus intermedius. Pneumonectomy was necessary, from which he made a goodrecovery. He has remained in good health to date (October 1960).
85
ture wound of the left ventricle near the left descendingcoronary artery. A laceration of the myocardium was also sutured. Thepostoperative electrocardiograms showed inversion of Tl, T2,and T4. The patient was evacuated to the Zone of Interior in goodcondition 8 weeks after operation.
INJURIES OF THE GREAT VESSELS
Since lacerations and penetrations of the great vessels wereapt to be quickly fatal, it is not surprising that the experience of the 2dAuxiliary Surgical Group included only two such injuries. The first patient diedon the operating table, from cardiac tamponade. The pericardium was distended byhemorrhage from a small laceration of the superior vena cava, and the fragmentwas recovered free in the pericardial sac.
The second patient was of interest because of the retained foreign body whichrested in close apposition to the ascending aorta and moved vigorously with eachcardiac pulsation (fig. 30). The vessel wall was presumed to have escapedinjury, and the patient was returned to the Zone of Interior without operationoverseas.
That this patient was likely to continue well was evident in the case historyof another soldier observed in the Mediterranean theater, who had harbored a.38-caliber bullet directly against the ascending aorta for the past 20 years(fig. 31). On fluoroscopy, the bullet was seen to move vigorously with eachpulsation of the aorta. In the interim, he had had no symptoms of any kind, andhe was returned to the Zone of Interior not because of the presence of thebullet but because of bronchial asthma.
MANAGEMENT OF CARDIAC WOUNDS
Official Policies
The infrequency of wounds of the heart susceptible tosurgical management is implicit in the scant attention paid to them in theinstructions for wound management issued during World War II. They are notmentioned in the circular letters published in either the Mediterranean or theEuropean theaters or in the "Manual of Therapy" published in theEuropean theater just before D-day. They are also not mentioned in WarDepartment Technical Bulletin (TB MED) 147, which was published in March 1945and which dealt with the care of battle casualties in the light of the wartimeexperience to date.
In fact, the only detailed instructions for management of wounds of the heartappeared in the thoracic surgery section of the military manual on neurosurgeryand thoracic surgery published in 1943 under the auspices of the Committee onSurgery of the Division of Medical Sciences of the National Research Council (10).
86
Policies in the Mediterranean Theater
Although foreign bodies within the heart were not a majorproblem in base installations in the North African campaigns or later in theItalian campaigns, it early became necessary to establish a policy concerningtheir management. Discussions by Col. Edward D. Churchill, MC, Consultant inSurgery to the theater surgeon, with the thoracic surgeons in the theater led tothe establishment of the following principles:
1. Only foreign bodies in the heart that were causing significant clinicalsymptoms or giving rise to significant clinical signs were to be removed inover-
87
88
sea base installations. All such casualties were to be sent to chest centers,for management by qualified thoracic surgeons.
Two groups of objects were believed likely to give trouble. The first wascomposed of missiles, particularly low-velocity fragments, lying in themyocardium, without complete penetration of the chambers. These, it was thought,would give rise to continuing intracardiac bleeding or to nonhemorrhagicpericardial effusion or to both. A number of such cases were managedsuccessfully by surgery. The second group was composed of intramyocardialforeign bodies impinging on major coronary vessels, which might give rise tosymptoms of coronary arterial insufficiency. Two such cases were treated, withcomplete relief of anginal symptoms after removal of the objects.
2. It was not believed that so-called chamber foreign bodies; that is,foreign bodies lying in an auricle or ventricle, would be a problem in anoversea theater. On the basis of long-term followup reports it was thought thatpatients in this group could be safely evacuated to the Zone of Interior forsuch surgery as might be necessary. On the other hand, if a chamber foreign bodymigrated intravascularly to the pulmonary vessels, removal in the overseatheater was considered indicated.
Experience confirmed the validity of this policy. Only a small number of truechamber foreign bodies were observed, none of which migrated to the pulmonaryvessels or gave rise to difficulty during the period of observation overseas.
Surgical Timing
When a patient with a suspected cardiac wound was encounteredin wartime, the decision as to its management could not be based, as in civilianlife, solely upon the presence of the wound and the patient's status. Inwartime, the heart wound frequently represented only one of several injuries,and both the diagnosis of the cardiac wound and the timing of surgery for itwere complicated by the presence of these multiple injuries. As already noted,only half of the cardiac injuries in this series were diagnosed before operationor post mortem, but, in view of the difficult circumstances, the percentage ofdiagnoses is gratifying rather than otherwise.
Decision as to surgery rested upon two considerations, the type of injury andthe presence or absence of a foreign body in the heart or pericardium. Threequestions had to be answered:
1. Could the cardiac lesion itself be corrected by surgery?
2. What was the effect of the patient's cardiac status on his ability towithstand surgery for other wounds?
3. Should the surgery be performed at a forward hospital, at the base, or inthe Zone of Interior?
When the heart was exposed for any reason at initial woundsurgery in a forward hospital, suture of the laceration was best accomplished atthe forward hospital. Efficient repair was unlikely in the base section after 10days
89
or more had elapsed after the injury. After this lapse,retraction of the edges of the myocardial defect and induration fromproliferation of fibroblastic tissue combined to defeat good approximation.
Foreign bodies, however, presented a different problem. Whenit was certain that a foreign body identified by roentgenologic examination wasjust within the myocardium or had merely penetrated the pericardium, it was bestto postpone surgery for 7 to 14 days and to evacuate the patient to a basecenter unless there were early and continued episodes of bleeding or cardiacdysfunction. Continued bleeding from a cardiac wound was always an indicationfor prompt thoracotomy. Otherwise, surgery was seldom an emergency. The dearthof diagnostic facilities and the lack of time for unhurried study in forwardinstallations made accurate localization in them difficult or impossible.
Specifically, indications for delayed removal of foreignbodies included cardiac pain, arrhythmia, abnormalities in previously normalelectrocardiographs, and suspected intrathoracic hemorrhage.
Preoperative Management
Resuscitation of patients with recognized cardiac woundsfollowed standard principles. Originally, in accordance with the work of Beck (6),it had been thought that if tamponade existed or was suspected, it would be ofno value to give blood or any other fluid intravenously, since it could notreach the heart. The experimental work of Cooper, Stead, and Warren (11)shortly before the war had shown that rapid intravenous infusion, with thesubsequent increase in blood volume, enabled dogs to withstand considerablyhigher intrapericardial pressure than when this measure was omitted. Elkin (3)had also shown its clinical value. Rapid blood transfusions were thereforestrongly recommended as part of the preoperative routine.
TECHNIQUE OF CARDIAC SURGERY
When a cardiac wound was considered in need of surgicalrepair or when such a wound was suspected, adequate exposure through an electiveapproach was mandatory. The tragedy of inadequate exposure was well illustratedby a case in the 2d Auxiliary Surgical Group experience in which exsanguinationoccurred from an unsuspected wound of the right auricle. The surgical incision,a low posterior thoracotomy, was intended for a thoracoabdominal wound and wasnot suitable for control of auricular hemorrhage.
Surgeons of the 2d Auxiliary Surgical Group believed very strongly thatextrapleural techniques should not be employed, however desirable they might bein civilian life. In the Duval-Barasty type of extrapleural surgery, bothauricles and ventricles were exposed simultaneously, and the argument wasadvanced that with such exposure, there was less possibility for missiles to
90
migrate from one chamber to the other. Exposure for posteriorlesions, however, was not satisfactory by the extrapleural technique. Suchoperations always took longer than operations performed by the transpleuraltechnique, and there was no time for them in the busy wartime operating room.Finally, the intrapleural damage and hemothorax almost always present in thesebattle-incurred wounds made extrapleural techniques so difficult that they wereentirely impractical.
Surgical Approach
An anterior transpleural approach (fig. 32A) was generallymost suitable. An intercostal incision was always employed unless the rib in theinvolved area was badly fractured. The third or fourth intercostal spaceprovided the best exposure for wounds of the auricle and the fifth or sixthinterspace for wounds of the ventricle. In general, more of the right ventriclecould be exposed through a left-sided than through a right-sided thoracotomy(fig. 32B).
The incision was carried to the sternum, and the internalmammary vessels were ligated and divided. When it proved necessary, an increasein vertical exposure could be obtained by transverse section of the sternum atthe level of the intercostal incision.
Usually, according to the suggestion of Beck (6), 10 cc. of 5 percentprocaine hydrochloride was injected into the pericardial sac several minutesbefore the heart was exposed. This practice materially cut down the incidence ofectopic beats while manipulations were in progress.
91
As a rule, the pericardium was found tense, with the cardiacpulsations weak or even imperceptible. If the pericardial wound was found, itwas enlarged as necessary. If it was not found promptly, the pericardium wasopened between stay sutures. Once intrapericardial pressure was relieved,bleeding became more profuse and cardiac contractions increased in force. Theheart wound was occasionally located before blood and clots were removed andbefore the heart began to beat actively. Suture was simple under theseconditions. More often, the wound was not located until free blood and clots hadbeen removed by suction.
Control of Hemorrhage and Rotation of Heart
In ventricular wounds, if the left index finger was placed over the wound,bleeding was usually controlled sufficiently to permit the passage of a suturedirectly under the finger. The suture, which was left untied, was held in theleft hand, so that hemostasis could be secured by traction while other sutureswere placed and tied. If the wound was on the diaphragmatic surface, on theposterior aspect of the heart, or behind the sternum, a stay suture wassometimes passed through the apex, by Beck's (6) technique, so that theheart could be rotated into a favorable position for suture of the wound.
Surgeons of the 2d Auxiliary Surgical Group found that the hand of theassistant (fig. 25C) made a better retractor than any suture. By this means, theapex of the heart could be rotated forward at least 90?, and cardiac movementwas considerably dampened. Spreading the fingers provided a sliding type ofretractor which permitted exposure of any portion of the cardiac wall.
If the lesions were anterior, the palming method (Sauerbruch grip) hadadvantages. By this technique, the third, fourth, and fifth fingers of thesurgeon's left hand were passed behind the heart. The index finger was anterior,and the thumb was used as necessary for hemostasis. This technique providedexcellent control of both the heart and the bleeding area.
Suture Techniques
Much of the wartime knowledge of actual cardiac suture techniques was owed tothe prewar work of Beck (6), Elkin (3), and Bigger (4), inparticular (fig. 33). The general techniques which they had promulgated pointedto the direction, and furnished the background, of most cardiac surgery.
Some lacerations in this series were deliberately notsutured, for two reasons: Some were considered too slight to require repair, andsome were so located, or were of such a character, that it was thought thatattempts at suture might lead to additional difficulties. Among the wounds leftunsutured were (1) superficial lacerations of the myocardium 1 or 2 mm. indepth, which were not bleeding, particularly if the left ventricle was involved;(2) round or oval lacerations left after removal of foreign bodies, especiallyin the apical region; and (3) lacerations near a major coronary artery, in whichthe risk of
92
nonrepair had to be weighed against the chances of thrombusformation. Wounds of the coronary vessels were not necessarily fatal. If smallbranches were bleeding, very careful ligature or suture of the individualbranches was highly satisfactory.
Wounds which had penetrated the cardiac chambers were alwayssutured, even though they were plugged by blood clots and were not bleeding whenthey were exposed. If they were not sutured, secondary hemorrhage was always apossibility.
In general, it was easier to repair lacerations of the auricle on the rightside than on the left. Since the right wall is thinner than the left, repair ofwounds in this area was always necessary, on the ground that after repair, thewall was thicker, and the scar from the sutured laceration stronger, than anaturally healed wound. Complete suture or some other type of repair wasconsidered mandatory if the depth of the laceration felt thin or if there wasany myocardial bulging. Without adequate suture, aneurysm of the myocardiummight develop later. Cases of this kind were reported by Loison (cited byLilienthal (12)).
Large wounds of the auricle deserve special mention. Even wounds as large as3 cm. might not be exsanguinating because the lung had collapsed against thewound or a clot had formed. The maneuver of covering the defect with the fingerin penetrating wounds, as practiced in ventricular wounds, was,
93
however, not practical in wounds of the auricle because ofthe thinness of the auricular wall. If sutures could not be placed immediately,the best plan was to grasp each edge of the laceration with fine forceps, whichwere then approximated, or to use temporary ligatures until sutures could beproperly introduced. If the wound was at the edge of the auricle, it would becompletely occluded with rubber-shod forceps.
Perforating through-and-through wounds of the chambers could be repairedsuccessfully if both wounds were superficial. No method of exposure waspractical for repairing a wound of the posteromesial surface of the rightauricle. The only two patients in the 2d Auxiliary Surgical Group series withthis type of wound both died of exsanguination, caused by hemorrhage from thefree wounds. If the cardiac wound could have been repaired, the mediastinalperforation might have sealed off.
A needle with a small eye or an atraumatic needle was used. Sutures wereinterrupted and were usually of braided No. 00 or No. 000 silk, preferably oiledor waxed. They were placed as close as possible to the wound edges but did notinclude them, if this could be avoided (it could not always be avoided inauricular wounds), because of the possibility of thrombus formation. Inmyocardial defects, sutures were taken into the epicardium and superficialmyocardium. No sutures included the endocardium (fig. 23). Great care was takenin the placing of sutures, since necrosis of the wound edges, particularly whenthe cardiac chambers were involved, could lead to fatal necrosis and secondaryhemorrhage. Sutures were tied during systole when possible and always withouttension.
Some lacerations, because of loss of substance as the result of the necrosisand contusion of surrounding tissues, were difficult if not impossible to suturecompletely. Then considerable ingenuity had to be exercised to secure closure,particularly when the laceration extended into a cardiac chamber. Free musclegrafts were useful, and probably should have been employed more frequently thanthey were. They could be laid in the defect, where they were held in place byfine sutures (figure 24B). They helped to fill the defect and were alsoinstrumental in checking hemorrhage or myocardial oozing.
As a further reinforcing mechanism, the pericardium was sutured over the areaof repair, after establishment of drainage for the pericardial sac into thepleural cavity by a cruciate incision. The edges of the pericardium could beeither approximated or imbricated (fig. 24C). This technique, combined with theuse of a muscle graft, provided solid repair. A flap of pericardium as an extralayer was also useful when bleeding had not been completely controlled bymyocardial suture.
Drainage was provided into the pleural cavity by closing the pericardium soloosely that fluid was able to escape. In the two cases in which this precautionwas omitted, pericardial effusion occurred (p. 65).
The chest wall was sutured with careful approximation of the anatomic layers.
94
ANALYSIS OF CASES
Management
Lacerations and perforations-Twenty-nine cardiac injuries werevisualized at operation and managed as follows:
Complete repair was accomplished in four lacerated wounds(one of the left ventricle, two of the right ventricle, and one of the rightauricle and right ventricle).
Partial repair was accomplished in two lacerations of the left ventricle.
Complete repair was accomplished in 10 perforating or penetrating wounds (6of the left ventricle, 1 of the right ventricle, 1 of the left auricle, and 2 ofthe right auricle).
Repair was attempted but proved impossible in two perforated wounds of theright auricle.
No repair was attempted in 11 wounds, including 10lacerations (8 of the left ventricle, 1 of the right ventricle, and 1 of theright auricle), and 1 perforating wound of the right ventricle.
Foreign bodies-It was the policy in the Mediterranean theater to beextremely conservative about the removal of foreign bodies in forward hospitalsor, indeed, in any oversea hospital. Of the 29 retained missiles in the 75cardiac wounds in the 2d Auxiliary Surgical Group experience, only 9 wereremoved, as follows:
Four (of four) were recovered from the pericardium.
One (of three) was recovered from the pericardial sac.
Three (of ten) were recovered from the myocaridum; five others were found atautopsy.
One (of four) was recovered from the cardiac chambers; three others werefound at autopsy.
The majority of fragments not removed were small, 0.5 cm. orless in diameter. In some cases, the condition of the patient did not warrant anextended search for them. The two foreign bodies not removed from thepericardial sac were not identified positively, but from the roentgenologicevidence and operative findings, it was considered highly likely that they werepresent.
Of the eight foreign bodies found only at autopsy, themissile was directly responsible for one death, because of an embolus to theheart (case 7, p. 80) and possibly for a second death (case 8, p. 80).
Postoperative Observations and Complications
Certain cardiac abnormalities were observed in some of the patients whosurvived surgery:
Eight developed friction rubs, some of which were audible for as long as 3weeks.
95
Two patients had apparent myocardial accidents, presumed to be infarctions.One occurred in the single stab wound in the series (p. 84). The other patientdeveloped a typical coronary occlusion 24 hours after operation, with transientauricular fibrillation, precordial pain, and circulatory collapse. This patienthad presented extrasystoles before operation, and at operation, it was necessaryto ligate a small bleeding terminal branch of the anterior descending artery. Inaddition, he had a clean superficial laceration of the cardiac apex, which wasnot repaired.
One patient had a transient pneumopericardium.
One patient developed hemiplegia after repair of a laceration of the leftventricle. One may speculate whether mural thrombi formed after operation.
Two patients developed massive pericardial effusions. In neither instance wasthe pericardium drained at operation. Both did well with pericardicentesis, andthere were no apparent sequelae.
Four other patients had delayed pericardial effusions between 2 and 6 weeksafter injury, for no apparent reason. All recovered under conservativemanagement. The clinical course suggested an irritative phenomenon rather than aflareup of latent infection. British observers in the Mediterranean theater, whoobserved a few similar cases, accepted this development as an indication forremoval of any retained foreign bodies as soon as the acute reaction subsided.The limited U.S. experience, as well as theoretical considerations, suggested amore benign interpretation, which remained for the future to clarify.
Fibrinous pericarditis developed in four cases and quite likely was presentin others in which it was not clinically apparent. The removal of dressings andbandages to establish this fact would not have been justified. In the affectedpatients, electrocardiograms usually exhibited the expected changes in the QRScomplexes (low voltage), with lesser degrees of alteration in the T-waves andS-T intervals.
Purulent pericarditis occurred in one case in the series in which thediagnosis of pericardial injury was missed at first:
Case 11-This patient sustained a severe penetrating shell-fragment woundof the epigastric region on 3 June 1944. Debridement revealed no pleuralpenetration, and no foreign body was visualized. Laparotomy revealed nointra-abdominal injury.
Five days after wounding, the patient became increasingly dyspneic, andcardiac enlargement was noted. Digitalis was administered, on a diagnosis ofmyocardial insufficiency. When he was admitted to a thoracic surgery center on11 June, 600 cc. of dark, bloody fluid, without odor, was removed from thepericardium, with prompt relief of dyspnea. Systemic penicillin therapy wasbegun. Five days later, only 15 cc. of fluid was obtained on pericardialaspiration, but 2 days later, 1,000 cc. was obtained. The patient becameprogressively more febrile, and on 17 June, the fluid removed (400 cc.) had anoffensive odor, showed early purulent transition, and on direct smear was foundto be teeming with organisms.
Pericardiostomy was performed immediately, by removal ofsegments of the fourth and fifth costal cartilages. A large metallic foreignbody, surrounded by a large piece of cloth, was found in the posterior recess ofthe left pericardial sac; it had driven
96
itself partly through the pericardium and into the leftpleural space. The missile, with its cloth investment, was removed, and thepericardium was emptied by suction and was tacked to the pectoral fascia to keepit widely open. No other provision for drainage was made. Cultures were reportedpositive for proteolytic clostridia.
The patient made a very rapid recovery, and the pericardialcavity was rapidly obliterated. There were no episodes of recurrent dyspnea orparadoxical pulse. The fever subsided promptly, and the patient was up and about18 days after operation.
Comment-The foreign body in this case was not visualized(fig. 34A) by roentgenograms because of the superimposition of the heart shadowand the density of the fluid in the pericardium. Its presence in the pericardiumwas suspected because of the failure to visualize it elsewhere and the nature ofthe wound. The patient's rapid convalescence is explained by the fact thatdrainage was instituted early, before the pericardial fluid became thick andintensely purulent. As a result, there was no recurrence of dyspneic episodesand no irregularities of the pulse. There was also prompt obliteration of thepericardial sac (fig. 34B). Fibrinous deposition of exudate on serosal surfacesis an important factor in delayed convalescence in such cases and furnishes anurgent reason for early drainage.
Fatalities
There were 30 deaths in the 75 cardiac injuries managed bythe surgeons of the 2d Auxiliary Surgical Group, 3 among the 18 pericardialinjuries and 27 among the 57 myocardial injuries.
All three deaths in the pericardial group occurred 48 hours or more afteroperation, and none could be attributed to the cardiac wound per se. Of the 27deaths in the myocardial injuries, 20 were, however, directly attributable tothe cardiac wounds. The seven remaining fatalities were variously attributableto associated wounds or to shock, bronchopneumonia, and anuria.
Ten cardiac wounds were seen only at autopsy, as follows:
97
Four lacerated wounds, including one of the left ventricle, one of the rightventricle, and two of both ventricles.
Six perforated wounds, including one of the left ventricle, one of the rightventricle, one of the left auricle, and three of the right auricle.
Causes of death-Exclusive of the 3 deaths in the 18 pericardialinjuries, the 27 deaths in the 57 wounds of the heart proper were distributed asfollows:
Eleven deaths, six due to cardiac causes, in sixteen pure contusions. Threeof these cardiac deaths were due directly to myocardial lesions and usuallyoccurred suddenly, from infarction or arrhythmia. In the three other cases, theheart wound played an essential contributory part in the fatality but was notthe only cause.
Five deaths, four due to cardiac causes, in the ten lacerations associatedwith contusions.
One death, due to the myocardial lesion, in the ten pure lacerating wounds.
Nine deaths, eight due to cardiac causes, in the nineteen perforating orpenetrating wounds. In four cases, the fatality was due to exsanguinatinghemorrhage from the cardiac wounds, and in two cases to tamponade.
One death, in a myocardial lesion, due to a cardiac embolus.
An analysis of the cardiac deaths (table 6) shows that 15 of the 20 followedwounds of the ventricles.
Time of death-The distribution of the 27 deaths in the series inrelation to the time of the fatality was as follows:
Two before operation, both as the result of the cardiac wound.
Ten, including four in thoracoabdominal injuries, beforesurgery was completed or immediately after operation. Eight were considered dueto the cardiac wound.
Four, including three thoracoabdominal wounds, between 1 and 5 hourspostoperative. Three were considered due to the cardiac wounds.
TABLE 6.-Distribution of 27 deaths in 56 combat-incurredcardiac injuries1
| Type of injury | Number of cases | Number of deaths | Anatomic distribution of cardiac deaths | |||||
| Cardiac | Other | Ventricles | Auricles | |||||
| Right | Left | Both | Right | Left | ||||
| Contusions | 16 | 6 | 5 | 2 | 3 | 1 | --- | --- |
| Lacerations | 10 | 1 | --- | --- | 1 | --- | --- | --- |
| Contusions and lacerations | 10 | 4 | 1 | 1 | 1 | 2 | --- | --- |
| Perforating or penetrating | 19 | 8 | 1 | 1 | 2 | --- | 4 | 1 |
| Embolus of heart | 1 | 1 | --- | 1 | --- | --- | --- | --- |
| 56 | 20 | 7 | 5 | 7 | 3 | 4 | 1 |
1This table does not include a self-inflicted stab wound, from which the patient recovered. It also does not include 18 combat-incurred pericardial injuries, 3 of which were fatal.
98
Two between 6 and 12 hours postoperative. Neither was due directly to thecardiac wound.
Six, including one thoracoabdominal wound, between 12 and 24 hourspostoperative. Four were considered due to the cardiac wound.
Three, including two thoracoabdominal wounds, after 24 hours. All wereconsidered due to the cardiac wound.
Of the 20 deaths considered directly due to the cardiac wound, 2 occurredbefore operation, 8 during or immediately after operation, 3 within 5 hoursafter operation, 4 within 13 to 24 hours postoperative, and 3 after 24 hourspostoperative.
Responsibility for cardiac fatalities-In 20 deaths attributed to woundsof the heart, either surgery was not done at all, or corrective surgery was notcompleted. An analysis of these cases indicates that in eight, surgery wouldprobably have benefited the patients and that in one other case, it mightpossibly have been beneficial. In the other 11 cases, surgery would not havebeen useful, or more extensive surgery than was carried out would have beenuseless. Of these 11 casualties, 4 were in such poor condition when they werefirst seen that they died promptly, either before or during operation. Another,thought to be in good condition, died suddenly during operation, and threeothers, also thought to be in good condition, died suddenly soon afteroperation. The other three patients in this group died after operation, soonafter symptoms of myocardial infarction had become evident.
When the analysis of the possible benefits of surgery, or of more completesurgery, is made in these 20 cases from the standpoint of the causative lesion,the following facts emerge:
1. The six casualties with contusions could not have benefited by operation.This is not a lesion which is ever benefited by surgery, nor is it a conditionin which early operation for other causes, however necessary it may be, is welltolerated.
2. Surgery would not have been useful in the single fatal lacerating wounduncomplicated by other cardiac damage. The patient had a pericarditis producedby contamination with gastric contents, though the exact role of the infectionin the fatal outcome cannot be stated precisely.
3. Operation would not have been useful in four cases ofmyocardial lacerations and contusions in which it was omitted, nor wouldadditional surgery have been beneficial in a fifth case in which the lacerationwas repaired. Damage was lethal in all four of these cases. In three, theanterior descending branch of the left coronary artery presented a traumaticthrombosis for at least half its length, and the fourth patient had an earlypericarditis produced by contamination from gastric contents. A fifth patient,with a myocardial laceration and contusion, might possibly have been helped bysurgery. He died suddenly, 4 hours after debridement of the thoracic wound. Atautopsy, a shell fragment 15 by 10 by 10 mm. was found in contact with thesternum, lying in a shallow, contused, lacerated wound of the right ventricle atthe base of the pulmonary
99
conus. It is possible that the continued presence of thismissile was responsible for propagating fatal ectopic stimuli. The pericardiumcontained 150 cc. of liquid blood, but the sac was not tense, and the mode ofdeath did not suggest that pressure from tamponade played any part in the fataloutcome.
4. Operation would probably have been useful in the fatal case in which theforeign body became embolic to the heart.
5. The largest group of cases in which surgery might havebeen beneficial consisted of seven penetrating or perforating wounds of thecardiac chambers. Repair of the defect would probably have succeeded in six ofthese cases and might have helped in the seventh. Four of the patients died ofexsanguination, one in the shock ward, two on the operating table, and the otherof an unrecognized perforating wound of the right auricle. In this case,original hemorrhage had apparently ceased when debridement of the thoracic wallwas done, but rapid exsanguination occurred before additional surgery wasperformed 36 hours after the injury.
There were two instances of tamponade in these seven cases.One was entirely unsuspected until autopsy. The second was recognized too latefor control, though it is doubtful that the patient could have survived, in viewof the severe associated thoracoabdominal wounds.
The mode of death in the remaining (seventh) case in this group is notentirely clear. Death occurred suddenly and was considered due to myocardialdysfunction. The patient had a through-and-through wound of the left auricle,and there was approximately 100 cc. of blood in the pericardium, without anyevidence of tamponade. It is speculative that repair of the defects might havebeen successful but quite obvious that a man with such injuries could notsurvive very long without surgery.
References
1. Makins, G. H.: Injuries to the Pericardium and Heart. In History of theGreat War Based on Official Documents. Medical Services. Surgery of the War.London: His Majesty's Stationery Office, 1922, vol. I, pp. 431-475, passim.
2. Tribby, William W.: Examination of One Thousand American Casualties Killedin Action in Italy. Report to Surgeon, Fifth U.S. Army, 1944, 6 vols. [Officialrecord.]
3. Elkin, D. C.: Wounds of the Heart. Ann. Surg. 120: 817-821, December 1944.
4. Bigger, I. A.: Heart Wounds. A Report of SeventeenPatients Operated Upon in the Medical College of Virginia Hospitals and aDiscussion of the Treatment and Prognosis. J. Thoracic Surg. 8: 239-253,February 1939.
5. Wood, Paul.: War Wounds of the Heart. Proceedings of theConference of Army Physicians, Central Mediterranean Forces, held at theIstituto Superiore Di Sanita Viale Regina Marguerita, Rome, 29 Jan. to 3 Feb.1945, pp. 23-25.
6. Beck, C. S.: Further Observations on Stab Wounds of the Heart. Ann. Surg.115: 698-704, April 1942.
7. Bright, E. F., and Beck, C. S.: Nonpenetrating Wounds of the Heart; AClinical and Experimental Study. Am. Heart J. 10: 293-321, February 1935.
8. Warburg, E.: Myocardial and Pericardial Lesions Due to Non-PenetratingInjury. Brit. Heart J. 2: 271-280, October 1940.
100
9. Yates, John L.: Wounds of the Chest. In The MedicalDepartment of the United States Army in the World War. Washington: GovernmentPrinting Office, 1927, vol. XI, pt. 1, pp. 342-442, passim.
10. Neurosurgery and Thoracic Surgery. Prepared and edited by theSubcommittees on Neurosurgery and Thoracic Surgery, Committee on Surgery,Division of Medical Sciences. National Research Council. Philadelphia andLondon: W. B. Saunders Co., 1943.
11. Cooper, F. W., Jr., Stead, E. A., Jr., and Warren, J. V.: The BeneficialEffect of Intravenous Infusions in Acute Pericardial Tamponade. Ann. Surg. 120:822-825. December 1944.
12. Loison, cited by Lilienthal, Howard: Thoracic Surgery-The SurgicalTreatment of Thoracic Disease. Philadelphia and London: W. B. Saunders Co.,1925, vol. I. p. 441.
