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History of Cardiac Trauma Surgery

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History of Cardiac Trauma Surgery History of cardiac trauma surgery A J Nicol, MB ChB, FCS (SA), PhD; P H Navsaria, MB ChB, FCS (SA), MMed (Surg); D Kahn, MB ChB, FCS (SA), ChM Department of Surgery, Groote Schuur Hospital, Cape Town, South Africa Corresponding author: A Nicol ([email protected]) The ancient Egyptians, although realising the diaphragm, of the small intestine, of the coronary artery and that blood in the the anatomical importance of the heart, stomach and of the liver is deadly.’[8,9] Aristotle pericardial sac could compress the heart and were largely responsible for the aura of (384 - 322 BC) wrote that ‘The heart again restrict its movement.[17] mysticism and superstition that enveloped is the only one of the viscera, and indeed the heart for centuries. The Egyptian Book the only part of the body, that is unable to The nihilism surrounding cardiac injuries of the Dead (c. 1567 BC) describes how, on tolerate any serious affection. This is but what continued and in 1804 John Bell published entry to the underworld, the jackal-headed might reasonably be expected. For, if the his Discourses of Nature and Care of Wounds, Anubis weighed the heart of the deceased primary or dominant part be diseased, there declaring that ‘there is so little to be done … against a statue of the goddess of truth and is nothing from which the other parts which and the signs and consequences are so clear, justice.[1,2] If the heart weighed the same, the depend upon it can derive sucour’.[10,11] Celsus that it is a waste of time to speak longer of dead person was admitted ‘to the company (1st century AD) recognised the clinical wounds of the heart’.[5,18] of Osiris and the blessed; if not, if his heart features of shock associated with a cardiac was heavy and laden with sin, it was cast to injury when he wrote in De Medicina that, There is dispute over who should be named the devouring beast Ammit’.[3] ‘When the heart is wounded much blood as the first modern cardiac surgeon. The two is lost, the pulse weakens, pallor becomes contenders are the extremely well-known extreme, a cold and foul sweat arises from the Baron Larrey and the almost unheard of Hippocrates recognised stricked body, the extremities become cold Catalonian surgeon called Francisco Romero. [9,12] that cardiac injuries were and speedy death follows’. Pliny the Elder These two men apparently performed the first (AD 23 - 79) felt that the heart ‘is the only open pericardiotomy at approximately the invariably fatal. one among the viscera that is not affected same time. Francisco Romero of Barcelona by maladies, nor is it subject to the ordinary performed an open pericardiotomy on a penalties of human life; but when injured, it patient with a pericardial effusion around Homer was the first author to narrate a produces instant death’.[9,13] 1810. He presented his memoir, Observatio cardiac injury in the Iliad (c. 950 BC), when experimentis confirmata, pro hydrope pectori, the Greek commander, Idomeneus, killed Claudius Galen (AD 130 - 200) expressed pulmonum anasarca, et hydropericardio the Trojan, Alkathoos.[4] his sentiment of the hopelessness of a cognoscendis; et nova methodus dittos morbos ‘Idomeneus smote him with a thrust of his cardiac wound: operandi, to the Society of the School of spear full upon the breast, and clave his 'When a perforation penetrated in one of Medicine in Paris in 1815. An incision was coat of bronze around him, that aforetime the cardiac ventricles, they (the gladiators) made over the costal cartilage of the 6th rib ever warded death from his body, but died on the spot, mainly by blood loss, and and after opening up the pericardial sac the now it rang harshly as it was cloven about even faster if the left ventricle was injured. fluid was allowed to drain into the pleural the spear. And he fell with a thud, and When the penetrating object did not pass space. These open surgical procedures were the spear was fixed in his heart, that still through the cardiac cavity but stopped at viewed at the time as being unnecessarily beating made the butt thereof to quiver.’ the cardiac muscle, some of the wounded aggressive and the Society did not endorse gladiators lived through the very day on his ideas.[19] TheIliad and the Odyssey contain numerous which they were wounded as well as the references to cardiac injuries.[5-7] Achilles’ following night; they eventually died later best friend, Patroclus, killed Sarpedon, the because of an inflammation.’[3] There is dispute over son of Zeus, with a spear to the heart. ‘The prostrate prince, and on his bosom The teaching of Hippocrates, Aristotle and who should be named as trod; Then drew the weapon from his Galen that all heart wounds were fatal was the first modern cardiac panting heart, The reeking fibers clinging followed until, in 1604, Cabriolanus found surgeon. to the dart; From the wide wound gush’d healed scar tissue in the hearts of individuals out a stream of blood, And the soul issued who had died by hanging.[14,15] The idea that in the purple flood.’ not all cardiac wounds were fatal was also Baron Dominique Jean Larrey, the suggested by Holerius.[9,16] Surgeon-in-Chief of Napoleon’s imperial Hippocrates recognised that cardiac injuries guard, made a number of contributions were invariably fatal. ‘A severe wound of Morgagni (1761) was the first to recognise to trauma surgery. He invented the ‘flying the bladder, of the brain, of the heart, of cardiac tamponade from an injury of the ambulance’ to rescue the wounded from the 206 CME June 2013 Vol. 31 No. 6 History of cardiac trauma surgery scene of battle. Previously, casualties were and other madness.’[21] He also remarked that Farina of Rome sutured the right ventricle considered to be a nuisance. He introduced ‘A surgeon who tries to suture a heart wound in a 30-year-old man who had been a system of triage to manage patients deserves to lose the esteem of his colleagues’.[22-24] stabbed in the left chest with a fi ne dagger according to the severity of their wounds In 1896 Paget wrote that ‘Th e surgery of the at the Spedale della Consolazione in March and also successfully decompressed the heart has probably reached the limits set by 1896. Th e 5th costal cartilage and rib were pericardial sac of a patient by catheter nature to all surgery; no new method and removed and fi ve silk sutures were placed drainage. Th e pericardiotomy that was no new discovery can overcome the natural into a 7-mm wound of the myocardium. performed by Baron Larrey was conducted diffi culties that attend a wound of the heart. On the 8th postoperative day the patient on Bernard Saint-Ogne, a 30-year-old It is true that heart suture has been vaguely died from a bronchopneumonia, but at infantryman who had attempted suicide proposed as a possible procedure and has autopsy the heart was found to be perfectly by stabbing himself in the chest aft er been done on animals, but I cannot fi nd that healed.[31,32] being accused of an off ence that he did not it has ever been attempted in practice.’[25] commit, on 18 March 1810.[20] Th e fi rst successful cardiac repair was performed by Dr Ludwig Rehn of Frankfurt ‘In the left side of the chest, the pericardium Between 1912 and 1914 on 9 September 1896. [33] A 22-year-old man, and the left lung were wounded, the knife Wilhelm Justus, was brought to the hospital passed through the fi ft h costal cartilage and there were more than in a state of collapse aft er sustaining a was still in the wound when he was brought 75 cardiac operations penetrating wound in the fourth interspace. into hospital. Frothy blood escaped in jets and the mortality Stimulants were administered, which was with each systole. Th e knife was withdrawn followed by improvement, but 24 hours later and the wound dressed with plaster; the rate appeared to be his condition was so much worse that the patient tore off the dressing and it was diminishing, with an patient was operated upon. Ether was used reapplied. Th e pulse was rapid and there was overall rate of around for narcosis.[34] A resection of the 5th left rib grave dyspnoea. Bleeding gave some relief. was undertaken and the pleura was cleared Some improvement took place, but later 45%. of blood. Dr Rehn describes the operation on he became worse, and in great distress further: ‘Th ere is continuous bleeding from requested Larrey either to open his chest or a hole in the pericardium. Th is opening is to give him a narcotic strong enough to send However, there was about to be a radical enlarged. Th e heart is exposed. Old blood him to sleep. Operation 45 days aft er injury, shift to surgical management. In 1876 and clots are emptied. Th ere is a 1.5 cm incision through the skin and cellular tissue Gottard Bulau of Hamburg developed gaping right ventricular wound. Bleeding is in the fi ft h space below the nipple, carefully the system of the underwater drainage controlled with fi nger pressure ... I decided carried deeper until pericardium felt. With of the pleural cavity. Th is was a huge to suture the heart wound. I used a small the left index fi nger on the pericardium as a milestone in the progress of managing guide an incision into the pericardium was penetrating chest trauma and overcoming made with a bistoury, the fi nger inserted, the inherent problem of the associated and the apex of the heart felt.
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