The evolution of the management of penetrating wounds of the heart.

In contrast to neurological surgery, which has its origins in the treppaned skulls of Neolithic man, the realization of cardiac surgery awaited the successful suture of a wound of the heart, an accomplishment of the nineteenth century. While the problem of pneumothorax has been cited as contributing to the delay in the development of surgery of the chest, exposure of the heart can be accomplished extrapleurally: hence, the late development of cardiac suture can be traced more to the ancient premise of the inviolability of the heart, a view which persisted up to the time of the first cardiorrhaphy. The successful demonstration of the heart suture in man quickly led to its widespread adoption. Subsequently, two schools of thought regarding the initial management of penetrating cardiac wounds developed, one advocating conservative treatment with pericardiocentesis, the other prompt cardiorrhaphy. The increasing safety of thoracotomy, along with an appreciation of the unpredictable and frequently catastrophic course following an initial favorable response to pericardiocentesis resulted in the gradual emergence of cardiorrhaphy as the procedure of choice, relegating pericardiocentesis to a diagnostic or temporizing measure.