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General Surgery
IV. Surgery of the Thorax

Stab-wound of the Pericardium:

suture, recovery

by H. C. Dalton

    H. C. Dalton of Saint Louis (Annals of Surgery, Feb 1895), relates the case of a man, aged twenty-two, who was stabbed in the breast during a fight, and complained subsequently of faintness and nausea, soon followed by dulness on the left side and dyspnœa. The wound was freely opened, and a considerable portion of the fourth rib excised; a divided intercostal artery was secured, and than a wound in the pericardium 2 inches in length became evident. The pleural cavity was opened, and after sponging out some blood clots, was subsequently irrigated with hot sterilised water; with some difficulty the wound in the pericardium was sutured with a continuous stitch, and the whole wound closed and dressed antiseptically without drainage. Perfect convalescence ensued. Dalton emphasises the difference between abdominal and thoracic wounds, in that all punctured wounds of the abdomen must be at once attended to by exploration, whilst in the thorax one would never explore without the supervention of grave symptoms.

Excerpt from: "General Surgery: IV. Surgery of the Thorax," The Year-Book of Treatment for 1884-1899, vol.15, Cassell & Co., Ltd (1899), page 208. (source)

Surgical Diseases and Injuries of the Heart

from A Treatise on Surgery by American Authors (1896)

    The following is a brief synopsis of a case reported by H. C. Dalton, M.D., of St. Louis in 18941: "A man in a fight was stabbed over the left breast; the wound was an inch in length and an inch and a half above the left nipple. There was little hemorrhage from the wound, and normal cardiac dulness was found on percussion. The percussion of the chest showed absence of dulness. The wound was closed and antiseptic dressings applied. Ten hours after admission to the hospital percussion revealed dulness over the entire left side, [his temperature had risen to 101ºF, his pulse rate to 112]1 and much pain was complained of. The patient was removed to the operating theatre and the dressings taken off, when it was found that blood and air gushed from the wound with each inspiration. An incision was accordingly made, eight inches in length, over and parallel to the fourth rib, and six inches of the rib resected., The intercostal artery having been tied, the pleural cavity was found full of clotted blood and fluid blood, which with each inspiration, poured from the wound with great force. The patient was turned on his left side, and with a long pair of forceps, armed with a sponge, the pleural cavity was cleaned of blood. Subsequently it was discovered that a transverse wound of the pericardium existed to the extend to two inches, and steps were taken to suture the lesion. In carrying out this procedure great difficulty was experienced, owing to the pulsation—at the rate of 140 per minute—of the heart. The pericardium with each pulsation of the heart rose and fell, and in order to carry into effect that which was being attempted, it was necessary to follow the movements of the organ. Ultimately, a continuous suture of catgut was then thoroughly irrigated with sterilized warm water, the external wound closed, without a drainage-tube, and antiseptic dressing applied. It may be noted that at several stages of the operation, which lasted an hour, the patient seemed to be dying, and in order to avert collapse hypodermic injections of whiskey and strychnia was resorted to. Before the pericardial wound was sutured, examination of the heart was made with a view to discovery of a wound in the organ, but no lesion was found. The patient made an uninterrupted recovery."

Excerpt from "Surgical Diseases and Injuries of the Heart," A Treatise on Surgery by American Authors, vol.2, by Roswell Park, publ. Lea Brothers (1896), Chap. III, page 130. (source)

Note: 1. Additional information from Cardiac Surgery, by Harris B. Shumacker, 
Indiana University Press (1992) page 12: "The procedure was reported in the state medical association's journal and another local periodical in 1894, and in Annals of Surgery the following year. In the latter Dalton made this revealing statement: 'I had no precedent to guide me, no authority to uphold me in attempting to sew up this wound over a heart that was beating at the rate of 140 per minute.'"

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