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 Pnnotnre and Inciaion of the Perioardium, 
 
 Delorme et Mignon. " Sur la ponction et I'incision du pericarde." 
 — Revue de Ghiriirgie, D^cembre, 1895. 
 
 [Commenced in the April Number.] 
 
 There are four methods of approaching the pericardium : 
 
 1. By trephining the sternum. 
 
 2. By passing close beneath the inferior border of the thoracic cage 
 beneath the seventh costal cartilage, starting from the xiphoid 
 appendix. 
 
 3. By puncture through an intercostal space. 
 
 4. By resecting one or two of the costal cartilages. 
 
 Trephining the sternum was advised by Riolan in 1648. The .sug- 
 gestion was accepted by Laennec, Bayer and by Skielderup. It was 
 only done once on the living by Malle. In this way he removed 300 
 grammes of serous liquid. The relief was instant, but the patient 
 ultimately succumbed to tuberculosis of the intestines and lungs. 
 
 Soft and superficial, the sternum is easily trephined. There is no 
 danger of wounding the internal mammary arteries, but there is 
 danger nf the bone becoming infected and suppurating, and also 
 danger of the fluid escaping into the cellular ti.ssue of the media- 
 stinum and there setting up inflammatory action. Another danger 
 difficult to avoid is the wounding of the right pleura. 
 
 Epigastric incision as a method of approaching the pericardium was 
 suggested to I). Larrey by observing a penetrating wound in a soldier, 
 in which the instrument entered between the xiphoid and seventh 
 costal cartilages passing through the pericardium from below up- 
 wards. 
 
 Tiie operation is ea.sy of performance, and the left terminal branch 
 of the internal mammary artery can be secured without any special 
 difficulty. But if the abdomec is distended the diaphragm may be 
 pushed up so far as to be in danger of being wounded, and then again 
 there is the danger of wounding the left pleura. 
 
 Puncture of the pericardium, since the attempt of Schub in 1840, 
 has been often performed. An ordinary trocar has been used in the 
 majority of cases, sometimes an aspirator needle and sometimes direct 
 puncture with a scalpel. -,- --. :^~ 
 
 I 
 1 
 
62 
 
 SURGERY. 
 
 As to the point of puncture, operators have been guided either by 
 the anatomy of the region or by the clinical signs. The pericardium 
 lies beneath the 2nd, 3rd, 4th and 5th intercostal spaces. It extends 
 a few centimetres to the right of the right border of the sternum, and 
 it has been suggested to puncture it to the right of the sternum. 
 
 The internal mammary artery passes 2 or 3 millimetres from the 
 border of the sternum in children and 10 to 15 millimetres in adults. 
 In the fourth interspace there is danger of wounding the heart if the 
 puncture is deep. 
 
 Aran, without regard to anatomical points and only bent on avoid- 
 in<r the wounding of the heart, chose the points where silence and 
 absence of bruits were the most complete. 
 
 The early operators used a hydrocele trocar, but the needle of an 
 aspirator is now genei-ally used and is to be recommended. After 
 discussing the method of Baizeau and Dieulafoy the authors advise 
 the following : 
 
 Along the left border of the sternum, that is, about 15 millimetres 
 from the median line, an incision is made through the skin, beginning 
 a Hnger's breadth below the lower border of the 7th costal cartilage, 
 passing upwards across the 6th and 5th intercostal spaces. This 
 incision is 4 centimetres in length. In the Gth interspace by prefer- 
 ence, if the space will admit the needle, otherwise in the 5th inter- 
 space, very exceptionally in the lower internal angle of the 4th 
 interspace, a No. 2 needle of J)ieulafoy is slowly inserted in apposition 
 to the left border of the sternum. When the needle has entered to 
 the level of the posterior surface of the sternum, or for a distance of 8 
 mm , the handle is very much depressed and the point of the needle 
 is carried upwards parallel with the posterior surface of the sternum. 
 When the point of the needle has been forced upwards 1 or 2 centi- 
 metres the handle is raised and the point carried forward until fluid 
 appears in the tube. After evacuation the incision is sutured. By 
 this method the internal mammary artery and left pleura are avoided 
 and the risks of wounding the heart are reduced to a minimum. 
 
 It is very important that the pleura be not wounded. If the peri- 
 cardial effusion is serous, probably little harm would result, but if 
 sanguinolent or purulent the result might be disastrous. Even by 
 the method recommended by the authors one is not absolutely certain 
 to avoid the pleura. They found in testing the question that in 32 
 cadavers, where the puncture was made in the 5th interspace, the 
 pleura was wounded 12 times, and when made in the 6th interspace 
 6 times. When punctured in the 4th or 3rd interspace the pleura 
 was pierced in nearly every instance. The lung is in less danger as it 
 is generally pushed aside by the effusion. Occasionally the heart has 
 
SURGERY. 
 
 53 
 
 been wounded, especially when adherent to the anterior wall of the 
 pericardium. This is not necessary fatal if a small needle be used. 
 
 Incision of the pericardium is performed after resecting portions of 
 the 5th and 6th intercostal cartilages. The following is recommended 
 and by this method the authors claim that the pleura and internal 
 mammary arteries are not endangered ; the pericardium is opened at 
 a dependent part, and in case of pericardial adhesion, there is no 
 danger of wounding the heart. 
 
 1. A vertical incision is carried one centimetre to the left of the 
 left border of the sternum from the inferior border of the 7th costal 
 cartilage to the upper border of the 4th. From the extremities of 
 this incision two transverse incisions, each 2 centimetres long, are 
 carried horizontally to the left. 
 
 2. The skin, cellular tissue and the attachments of the pectoralis 
 major are elevated and the cartilages laid bare. 
 
 3. The 5th costal cartilage is separated from the border of the 
 sternum and the soft parts detached from the liorders and under 
 surface and tljen forcibly elevated, pressure being made upon it 4 
 centimetres from the edge of the sternum, so that the cartilage is 
 fractured at this point instead of at its junction with the rib. The 
 6th cartilage is treated in the same manner. 
 
 4. The perichondrium is then incised vertically and removed, when 
 the triangularis sterni is exposed with the internal uiammary vessels 
 lying upon it. 
 
 5. A director is then passed along the border of the sternum, and 
 with the finger the pleura is separated from the pericardium and 
 pushed to the left with the triangularis sterni muscle and the internal 
 mammary vessels. 
 
 6. The opaque white pericardium being now exposed, is pinched 
 up and incised ; a director is inserted into the opening and with a 
 pair of scissors the opening is enlarged. 
 
 If found necessary the 4th cartilage can also be removed. 
 
 Since the introduction of antiseptic methods, incision of the peri- 
 cardium is coming more into favour, as in this way one is certain of 
 not wounding the pleura, mannnary vessels, lung or heart, and the 
 fluid can be removed with certainty, as well as fibrinous clots, and 
 medicated solutions can be used if thouglit advisable. 
 
 As these patients often take cholorform or ether badly, it is suggested 
 that it is often advisable to puncture or aspirate first, perhaps with the 
 aid of a local anaesthetic, the more complicated operation of incision 
 being reserved until the heart has recovered itself at least partially. 
 
 In the recumbent position there is less danger of syncope and the 
 operator can work to greater advantage. Geo. E. Arinutvo'ng. 
 
Method of Operating in Appendicitis. 
 
 White. " Should the appendix be removed in every case of appen- 
 dicular abscess." — Annah of Surgery, June, 1896. 
 
 McBuRNEY. " Transactions of the section on general surgery of the 
 College of Physicians of Philadelphia." — Ibid. 
 
 The writer, after mentioning several points which still admit of 
 legitimate differences of opinion, discusses this question at considerable 
 length. In the cases where the operation is undertaken early, that is 
 before the third or fourth day, there is rarely any doubt about the pro- 
 priety of removing the appendix, but when we come to the later cases, 
 where a strong wall of adhesions has been formed about the abscess, the 
 case is not so clear. 
 
 Some surgeons would remove the appendix in every case, fearing 
 either a return of the disease or a fa3cal fistula. The views of 
 a number of surgeons are quoted, and all are strongly of the opinion 
 that in certain cases it is not well to disturb things too much, but to 
 be content with draining the abscess cavity, cleansing and packing 
 it with iodoform gauze, rather than run the risk of infecting the gen- 
 eral peritoneum by more radical methods. The writer sums up as 
 follows : " Every medical man knows of the inflammc'^ory obliteration 
 of mucous channels, of the retrograde metamorphosis and disappear- 
 ance of infected sloughs, or of their fibroid transformation into 
 cicatricial tissue ; of the shutting in of abscess cavities with infected 
 walls, and of the coincident death of the bacteria therein as the 
 supply of pabulum is cut off"; of the spontaneous healing of ffiBcal 
 fistulse. On the other hand, most surgeons of to-day have knowledge 
 of cases in which patients with almost purely local symptoms, in 
 excellent general condition and with distinctly circumscribed abscess, 
 have died of general peritonitis within forty-eight hours after the 
 removal of a deeply-imbedded and adherent appendix." 
 
 In the discussion which this paper evoked Dr. McBumey mentioned 
 two dlasses of abscesses which may be met with as a result of suppura- 
 tion about the appendix. In one the pus has already approached the 
 anterior abdominal wall and the abscess can be evacuated without 
 opening the general peritoneal cavity. If, in such a case, the appendix 
 forms an integral portion of the ban-ier which protects the peri- 
 
 
SUROERY. 
 
 55 
 
 toneum, no manipulation should be practised. The other form of 
 abscess admits of different treatment. Here the pus and appendix 
 are suri'ounded by coils of intestine, and the whole mass lies back in 
 the abdomen away from the anterior abdominal wall. Here one 
 must open the general peritoneal cavity as a first step. It is then 
 possible, with gauze or sponges, to isolate the infected area until the 
 mass is unravelled, the appendix removed and the parts cleansed. 
 Every case of suppurative appendicitis is ready for operation as soon 
 as a diagnosis can be made, and the speaker did not agree with 
 Treeves that very few cases required operation before the fifth day. 
 " It is much better to carefully and deliberately approach the abscess 
 than to wait for the abscess to come to the point." 
 
 In the course of his paper Dr. White gives the following rules for 
 operation as being such that few, if any, surgeons will dissent from 
 them : " Immediate operation is indicated whenever the onset of a 
 case of appendicitis is marked by both suddenness and|severity ; when- 
 ever, during even a mild attack, the symptoms at the end of twenty- 
 four hours are unrelieved or are growing worse ; whenever, in cases 
 seen later, a firm, slowly-forming, well-defined mass is to be felt in 
 the right iliac fossa ; whenever at any time a sudden increase in the 
 acuteness of the pain arid a rapid <.liffusion of tenderness occur ; when- 
 ever there is good reason for believing the appentlix infection to be 
 tubercular in character; whenever attacks of any type have been 
 numerous, or are increasing in either number or gravity, or have 
 unfitted the patient for work or activity, or have caused local symp- 
 toms which are permanent and persistent or have at any tiine put 
 the patient's life in great danger." Robt. G. Klrkpatrick. 
 
 \ 
 
 Puncture and Incision of the Pericardium. 
 
 Delorme et Mignon. " Sur la ponction et I'incision du pericarde-" 
 — Revue de Ckirurgie, 10 Janvier, 1896. 
 
 (Commenced in the April Number.) 
 
 In their final article, Delorme and Mignon discuss the results of 
 puncture and incision of the pericardium. 
 
 They have collected 102 cases ; of these 61 are reported to have 
 died, 36 to have been cured, and in two instances the results are not 
 given by the operators. 
 
 They contend, and rightly, that these figures do not truly represent 
 the benefits that may be derived from puncture and incision, as in 
 many of these cases the operation was performed as a last resort, the 
 patient really dying from lesions developed before the operation was 
 
56 
 
 SURGERY. 
 
 porformed. They ui'ge that if it can be shown that puncture and 
 incision of tlie pericardium are sometimes followed by cure and 
 always, by amelioration of the symptoms, that they have gained their 
 cause. They report one case where death was undoubtedly caused by 
 the operation. The trocar had been forced through the left 4th inter- 
 space, close to the sternum. The operator withdrew two ounces of 
 blood ; five minutes afterwards the patient died from haemorrhage 
 into the pericardium. The autopsy showed that the trocar had pene- 
 trated the right ventricle of the heart on the middle of its anterior 
 surface. 
 
 In a few instances a fluid, sero-sanguinolent at the time of opera- 
 tion, became purulent afterwards. This may have been due to dirty 
 instruments and imperfect technique. 
 
 Many of the unfortunate results are avoidable. 
 
 Patients bear the operation well. 
 
 Of 100 cases, 82 were punctures and 18 incisions. Of the 82 punc- 
 tures 54 died and 28 recovered, a mortality of 65 p.c. Of the 18 
 incisions 7 died and 11 recovered, or a mortality of 38 p.c. 
 
 These figures speak strongly in favour of incision as compared with 
 puncture. 
 
 These articles are of great value and are well illustrated, and they 
 lead one to think that there is a legitimate field here for the surgeon 
 to step in and do useful work. Qeo. E. Armstrong.