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entricle； the endocardial wound being 3/8 inch long。 Both the pericardium and left pleura were distended with fresh blood and large clots。 Church reports a case of gunshot wound of the heart in a man of sixty…seven who survived three hours。 The wound had been made by a pistol bullet （32 caliber）； was situated 1 1/4 inches below the mammary line； and slightly to the left of the center of the sternum； through it considerable blood had escaped。 The postmortem examination showed that the ball had pierced the sternum just above the xiphoid cartilage； and had entered the pericardium to the right and at the lower part。 The sac was filled with blood； both fresh and clotted。 There was a ragged wound in the anterior wall 1/2 inch in diameter。 The wound of exit was 5/8 inch in diameter。 After traversing the heart the ball had penetrated the diaphragm； wounded the omentum in several places； and become lodged under the skin posteriorly between the 9th and 10th ribs。 Church adds that the 〃Index Catalogue of the Surgeon…General's Library〃 at Washington contains 22 cases of direct injury to the heart； all of which lived longer than his case： 17 lived over three days； eight lived over ten days； two lived over twenty…five days； one died on the fifty…fifth day； and there were three well…authenticated recoveries。 Purple tabulates a list of 42 cases of heart…injury which survived from thirty minutes to seventy days。
Fourteen instances of gunshot wounds of the heart have been collected from U。S。 Army reports； in all of which death followed very promptly； except in one instance in which the patient survived fifty hours。 In another case the patient lived twenty…six hours after reception of the injury； the conical pistol…ball passing through the anterior margin of the right lobe of the lung into the pericardium； through the right auricle； and again entered the right pleural cavity； passing through the posterior margin of the lower lobe of the right lung； at the autopsy it was found in the right pleural cavity。 The left lung and cavity were perfectly normal。 The right lung was engorged and somewhat compressed by the blood in the pleural cavity。 The pericardium was much distended and contained from six to eight ounces of partially coagulated blood。 There was a fibrinous clot in the left ventricle。
Nonfatal Cardiac Injuries。Wounds of the heart are not necessarily fatal。 Of 401 cases of cardiac injury collected by Fischer there were as many as 50 recoveries； the diagnosis being confirmed in 33 instances by an autopsy in which there were found distinct signs of the cardiac injury。 By a peculiar arrangement of the fibers of the heart； a wound transverse to one layer of fibers is in the direction of another layer； and to a certain extent； therefore； valvular in function； it is probably from this fact that punctured wounds of the heart are often attended with little or no bleeding。
Among the older writers； several instances of nonfatal injuries to the heart are recorded。 Before the present century scientists had observed game…animals that had been wounded in the heart in the course of their lives； and after their ultimate death such direct evidence as the presence of a bullet or an arrow in their hearts was found。 Rodericus a Veiga tells the story of a deer that was killed in hunting； and in whose heart was fixed a piece of arrow that appeared to have been there some time。 Glandorp experimentally produced a nonfatal wound in the heart of a rabbit。 Wounds of the heart； not lethal； have been reported by Benivenius； Marcellus Donatus； Schott； Stalpart van der Wiel； and Wolff。 Ollenrot reports an additional instance of recovery from heart…injury； but in his case the wound was only superficial。
There is a recent case of a boy of fourteen； who was wounded in the heart by a pen…knife stab。 The boy was discharged cured from the Middlesex Hospital； but three months after the reception of the injury he was taken ill and died。 A postmortem examination showed that the right ventricle had been penetrated in a slanting direction； the cause of death was apoplexy； produced by the weakening and thinning of the heart's walls； the effect of the wound。 Tillaux reports the case of a man of sixty…five； the victim of general paralysis； who passed into his chest a blade 16 cm。 long and 2 mm。 broad。 The wound of puncture was 5 cm。 below the nipple and 2 cm。 to the outside。 The left side of the chest was emphysematous and ecchymosed。 The heart…sounds were regular； and the elevation of the skin by the blade coincided with the ventricular systole。 The blade was removed on the following day； and the patient gradually improved。 Some thirteen months after he had expectoration of blood and pus and soon died。 At the necropsy it was seen that the wound had involved both lungs； the posterior wall of the ventricle and the inferior lobe of the right lung were traversed from before backward； and from left to right； but the ventricular cavity was not penetrated。 Strange to say； the blade had passed between the vertebral column and the esophagus； and to the right of the aorta； but had wounded neither of these organs。
O'Connor mentions a graduate of a British University who； with suicidal intent； transfixed his heart with a darning…needle。 It was extracted by a pair of watchmaker's pliers。 In five days the symptoms had all abated； and the would…be suicide was well enough to start for the Continent。 Muhlig was consulted by a mason who； ten years before； had received a blow from a stiletto near the left side of the sternum。 The cicatrix was plainly visible； but the man said he had been able to perform his daily labors； although at the present time suffering from intense dyspnea and anasarca。 A loud bellows…sound could be heard； which the man said had been audible since the time of reception of the injury。 This was a double bruit accompanying systole； and entirely obscuring the physical signs。 From this time the man speedily failed； and after his death there were cicatricial signs found； particularly on the wall of the left ventricle； together with patency of the interventricular septum； with signs of cicatrization about this rent。 At the side of the left ventricle the rent was twice as large and lined with cicutricial tissue。
Stelzner mentions a young student who attempted suicide by thrusting a darning…needle into his heart。 He complained of pain and dyspnea； in twenty…four hours his symptoms increased to such an extent that operation was deemed advisable on account of collapse。 The 5th rib was resected and the pleural cavity opened。 When the pericardial sac was incised； a teaspoonful of turbid fluid oozed out； and the needle was felt in an oblique position in the right ventricle。 By pressure of a finger passed under the heart； the eye of the needle was pressed through the anterior wall and fixed on the operator's finger…nail。 An attempt to remove by the forceps failed； as the violent movements of the heart drew the needle back into the cavity。 About this stage of the operation an unfortunate accident happenedthe iodoform tampon； which protected the exposed pleural cavity； was drawn into this cavity during a deep inspiration； and could not be found。 Notwithstanding subsequent pneumothor