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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

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.

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.

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

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.