Suture of a stab wound of the heart.

Over many centuries, from the early writings of Galen, 'the father of Medicine', wounds of the heart were considered fatal and outside the remit of surgery. With the advent of anaesthesia, (ether was introduced by William Morton in 1846) and of antiseptic surgery, (Joseph Lister's first publication was in 1867), there was an explosion in the surgery of the abdominal cavity, the chest, the skull and the limbs, yet the heart was considered by the surgical fraternity to be the 'no-go' area of the body. Theodor Billroth, Professor of Surgery in Vienna and himself a pioneer of modern surgery, (he performed the first successful partial gastrectomy for carcinoma of the stomach in 1881), wrote "the surgeon who would attempt to suture a wound of the heart should lose the respect of his colleagues". In London, Stephen Paget, in 1896, wrote: "No new method and no new discovery can overcome the natural difficulties that attend a wound of the heart. It is true that suture has been vaguely proposed as a possible procedure and has been done in animals but I cannot find that it has ever been attempted in practice". (In fact, the heart is an amazingly tough and efficient pump that goes on working, year after year, without ever stopping for a service!).

What the ancients knew of the fatal anatomic consequences of wounding of the lower thorax.

One of the most important lessons concerning the relevance of human anatomy to surgical diagnosis to be taught to medical students and first-year surgical residents concerns their sometimes poorly understood relationship of the structure of the lower thoracic cavity to the organs within the upper abdominal cavity. To make this indelibly clear, in surgical anatomic and clinical lectures given during the past 20 years, I have chosen to present the earliest Biblical examples of the ancient's knowledge of this critical relationship as regards wounds of the thorax specifically given to injure the liver and thus to produce a rapid and certain death. The first two concern the technique of assassination used by the warring factions of the House of King Saul and the followers of the House of David, which resulted in his succeeding to the kingship of Israel after the death of King Saul in the 10th century BC. The second example is the coup de grâce administered in 30 AD to the crucified Jesus by a Roman centurion to hasten His death. In all three cases, the evidence, in the first two cases explicit and in the third strongly implied, is that the executioners knew that a stab wound of the lower thorax on the right would lead to a rapid death by exsanguination because "the liver was suspended there." The importance of this understanding, made indelible by these examples discussed herein, is to insure the recognition by any medical student or surgical resident that any penetrating wound of the lower thorax may imply a much more serious injury to an intra-abdominal organ, and this must be rapidly and fully investigated.

Ludwig Rehn (1849-1930): the German surgeon who performed the worldwide first successful cardiac operation.

Ludwig Rehn, a German surgeon, performed the worldwide first successful cardiac operation in 1896 when he repaired a stab wound to the heart by direct suture. When he presented his work one year later at a surgical conference this pioneering operation evoked considerable ethical discussion. Rehn's surgical contributions also include carrying out the first thyroidectomy in 1880 and clarifying the causes of cancer in workers in the local aniline factories.

[History of trauma care]. / Istoria îngrijirii pacientului traumatizat.

BACKGROUND: Since its inception, the man suffered injuries through falls, fire, drowning and interpersonal conflict. While the mechanism and frequency of different specific injuries has changed passing of millennia, trauma remains an important cause of mortality and morbidity in modern society. Although the war is presented as one of the four knights of the Apocalypse, we must emphasize the important developments of surgical experience during war. The purpose of this study is to highlight the lessons learned during the history and how they changed the modern trauma care. METHOD: Systematic review of English language literature using computer searching of Library of Medicine and the National Institutes of Health International MEDLINE database using PubMed Entre interface. RESULTS: The first historical record of a trauma medical care is 3605 years ago. Over the past decades, one of the most important changes in trauma patient care is the selective nonoperative management (SNOM) of significant abdominal visceral injuries. SNOM was first described in 1968, for splenic trauma, by Upadhyay and Simpson. It was accepted much later for liver injuries. Beginning from 1960 - 1970, SNOM was introduced for abdominal stab wounds. Exploratory laparotomy remains the standard approach for abdominal gunshot wounds until 1990, when centers from United States and South Africa first reported cases successfully managed nonoperatively. CONCLUSIONS: The trauma surgery has evolved continuously over the centuries, according to more and more severe modem injuries.

Nonoperative management of abdominal gunshot wounds.

Mandatory surgical exploration for gunshot wounds to the abdomen has been a surgical dictum for the greater part of this past century. Although nonoperative management of blunt solid organ injuries and low-energy penetrating injuries such as stab wounds is well established, the same is not true for gunshot wounds. The vast majority of patients who sustain a gunshot injury to the abdomen require immediate laparotomy to control bleeding and contain contamination. Nonoperative treatment of patients with a gunshot injury is gaining acceptance in only a highly selected subset of hemodynamically stable adult patients without peritonitis. Although the physical examination remains the cornerstone in the evaluation of patients with gunshot injury, other techniques such as computed tomography, diagnostic peritoneal lavage, and laparoscopy allow accurate determination of intra-abdominal injury. The ability to exclude internal organ injury nonoperatively avoids the potential complications of unnecessary laparotomy. Clinical data to support selective nonoperative management of certain gunshot injuries to the abdomen are accumulating, but the approach has risks and requires careful collaborative management by emergency physicians and surgeons experienced in the care of penetrating injury.

[One hundred years ago --Jules Fontan and the wounded heart]. / Il y a cent ans--Jules Fontan et le coeur blessé.

On the event of the centennial of the first wound of the left ventricule cured by suture, the author recalls the conditions under which Jules Fontan, surgeon of the Navy, obtained this memorable success. He recalls the first observation and analysed the obstacles which this surgeon had to overcome to finally open the era of surgical treatment of heart wounds caused by knife fights. A comparative study of diagnostic and therapeutic approaches implemented one hundred years later highlights the advances made in the area of heart wound surgery and also in planned heart surgery for which the 20th century will remain of all achievements.

Duels, doctors and death.

Duelling as a method of settling disputes between gentlemen was practised in the British Isles and on the Continent from the 16th to the beginning of the 20th century. In early duels the victory would go to the better swordsman, but the use of pistols not only made the contest more deadly, but also more democratic. The social aspects, the indications for a challenge, the material and methods and the mortality and morbidity of the contest are considered. Mention is made of a case in which John Hunter was consulted. Its management, progress and autopsy findings are described together with Hunter's thoughts about it and the management of similar wounds.