Galen (second century), by Scultetus in 1662, and was in use in 1707,
as {594} shown in Anel's work, in 1742 in Laurence Heister's work, by
Ludwig and Lehren in 1768, again in 1796 (Benj. Bell), yet it had been
abandoned and lost sight of, with the exception of Laennec's suggestion
of its application in the form of a cupping-glass over the orifice of
puncture, until Guérin (1841) used it. The author followed Trousseau's
clinics in 1849 and 1850, and saw him repeatedly operate with Reybard's
canula guarded by gold-beater's skin, but never with Guérin's suction
apparatus. The French seemed to have lost sight of it until 1865, when
Guérin, at the French Academy, recalled attention to it, showing how he
aspirated liquids, instead of allowing them to flow outward after the
puncture. His apparatus consisted of a curved trocar, the end of which
was made tapering and sharp enough to puncture the thorax through the
skin and the muscles; of a pump, the piston of which was perfectly
adjusted to produce a vacuum; and of an adjuster at the extremity of
the pump, consisting of a stopcock which enabled the operator
alternately, without removing the instrument, to aspirate the fluid and
evacuate it into a basin. Wyman's pump, invented in 1850, was arranged
very much in the same way, only it contained valves which were opened
and closed by the movement of the barrel, to enable the operator to
suck out the fluid and then force it out of the pump. After the
operation the skin, being drawn over and closing the orifice, acted as
a valve which prevented at the same time the entrance of air and the
escape of fluid. Dieulafoy, in November, 1869, invented his aspirator,
which is based upon the same principles as those used by Guérin (1841)
and by Wyman and Bowditch (1850)--namely, pneumatic aspiration, which
the vacuum of the air-pump supplies. Guérin's instrument was large and
costly. Wyman's trocar was of a very small diameter, being only
one-twenty-fourth of an inch, and the canula but little larger. This
was attached, at first, directly to the aspirating syringe, afterward
by means of a flexible tube. With this apparatus Wyman demonstrated
that tissues could be safely punctured and cavities evacuated without
the admission of atmospheric air, that the wound, causing but a drop or
two of blood, was followed by no inflammation, and that no dressing was
required. The smallest trocar used previously to Wyman's was that of
Roe, which was one-twelfth of an inch in diameter. From 1850, Bowditch
appreciated the great value of Wyman's invention, as shown in one of
the first operations on a patient of his. He adopted and practised it.
His position as professor of diseases of the chest, and his great
reputation in that branch, gave him an extensive practice and brought
him many cases of pleurisy. He met with great opposition from the
surgeons and prominent practitioners of the country, but his results
were so favorable that he forced an unwilling and an unbelieving
profession to accept, as he expresses it, "the beautiful thought of
Wyman of thoracentesis or aspiration with a fine needle." "I considered
the operation so simple, and yet so effectual, and never harmful, that
I deemed it my duty to print cases illustrative of its value." Bowditch
had been for eight or ten years endeavoring to get some effective plan
of opening the chest without risk. He readily caught at Wyman's plan,
and he operated so frequently and successfully as to demonstrate its
value to the medical public both of this country and of Europe. As he
states,[313] it was, in fact, what he had been for years longing
for--viz. a simple and painless, or almost painless, operation for
removing fluids from the thorax--one that could be done without danger
and leave no open wound. Bowditch relates[314] that when he visited
Europe, nine years after his first publication of cases, he showed the
instrument in England, Scotland, France, and Germany, and that he met
with very indifferent recognition of its value. Only W. T. Gardner of
Edinburgh and Budd of London seemed to appreciate the plan. They had
instruments made after the American pattern. All others had no faith in
the operation. In Paris his old master, Louis, smiled {595}
incredulously at his enthusiasm for it and doubted its necessity. At
Vienna Skoda turned with apparent scorn and left the room as Bowditch
was demonstrating its employment. The Parisian authors, Woillez, Peter,
Moutard-Martin, Peyrot, and others, do not even mention Bowditch, but
give Trousseau alone the credit of popularizing thoracentesis.
[Footnote 313: Unpublished MSS., 1883.]
[Footnote 314: _Ibid._]
Trousseau's first publication was in 1843, and yet in 1859 there was no
general adoption of the operation, nor was there until 1869, when
Dieulafoy rediscovered Wyman's wonderful improvement of the application
of negative force to draw out fluids from the chest.
In estimating the value of the substitution of aspiration for the
trocar-and-canula method, we must bear in mind that with the latter
there was danger of the introduction of air into the thoracic cavity,
of the production of fistulous orifices, and the too rapid, and
therefore dangerous, evacuation of the fluid. Moreover, there are cases
where the trocar and canula is not effectual, although the quantity
effused be considerable--where, indeed, the fluid cannot flow out,
although the canula be pushed in actual contact with the fluid. The
explanation of this is now understood. The fluid is kept in the pleural
sac by a negative pressure of from 4 to 5 inches of water (Stone), 6
millimeters mercury (Donders), 5 millimeters mercury (M. Foster),
exercised by the lung in its elastic contraction, and by the passive
tension of the arched diaphragm. The fluid has no tendency to flow out,
and this suctional pulmonary force must be antagonized by an external
suctional force, that of aspiration, before the fluid can be withdrawn.
The invention can best be appreciated from the standpoint reached by
modern investigations of the physics of the living mechanism of the
chest. The principle of applying suctional force in pleurisy is in
imitation of nature's gentle methods in connection with respiration. We
have shown that most of the dangers connected with aspiration are
caused by not taking into consideration the adjustment of lung-tension
with thoracic resilience, and consequently of using too great negative
force and withdrawing the fluid too rapidly and in too great quantity.
Thoracentesis by aspiration, with greater or less force as may be
necessary, is now placed upon a scientific basis. We claim that this
modern method is an American invention--that Morrill Wyman was the
discoverer and H. I. Bowditch the utilizer of the discovery. As such
they may be regarded as benefactors of the human race.
It is extraordinary that Trousseau never alluded to Bowditch's
operations, and that Dieulafoy should never have heard of them.
Fraentzel acknowledges that Bowditch was the first to introduce
aspiration into practice. The Germans have been very slow in
appreciating its value. Fraentzel states that he did not use it until
1871, and that it was not until 1879 that it had in Germany any ardent
supporters. Bowditch[315] has now operated 387 times upon 246 patients
without any unpleasant result.[316] The distinctive points in
Dieulafoy's ingenious modification of the aspirator are that the
needles are very fine, even one-half of a millimeter in diameter; that
the barrel of the exhausting pump is of glass; that there is a
pre-existing vacuum; that we are not compelled to jar the side of the
patient by the process of pumping, and moreover by turning the cock we
produce at once a vacuum in the needle itself, and know with certainty
the moment the fluid is reached, and can see it flow through the glass
index in the tubing, even if it be in drops. We can judge of the nature
of the fluid, whether it be serum, pus, or blood. The minuteness of the
needle is a great cause of safety, because it allows the fluid to flow
so gradually that the lung has time to expand slowly. We can in an
instant arrest the flow of the fluid by turning the stopcock, and if
necessary by drawing out the needle. By giving the needle a downward
direction after it {596} enters the cavity, we prevent the point from
pricking the lung. So small an orifice is made that even if the needle
does touch the lung, there is no danger, for the orifice closes over at
once. As Dieulafoy claims, "the fineness of the needle guarantees the
harmlessness of the puncture." Castraux's concealed point (invented in
1873), and Fitch's (of Nova Scotia) protected canula (invented in
1873), are valuable additions to the aspirator-needle. These
dome-trocars, as they are called, prevent the possibility of injuring
the lung, for the sharp-pointed needle, after it has penetrated the
pleural cavity, is at once, by a slight movement, converted into a
blunt-pointed needle with an orifice near the end. With these very fine
needles the force is sufficient to draw up the thickest fluids. We are
compelled to admit that Dieulafoy's instrument is a great advance on
any other that has been invented. Its simplicity, its easy application,
its safety, have rendered paracentesis a harmless operation and one of
great value in serous effusions. While Guérin and Wyman may both claim
priority of invention, all must admit that Dieulafoy has improved upon
their ideas and given us a beautiful and effective instrument. There
have been proposed, since Dieulafoy showed his instrument in 1869, no
less than forty other aspirators, modifications in form or dimensions
of his apparatus. Of these, to us the most valuable is Potain's bottle
aspirator, with which aspiration can be so easily and effectually
employed. It is simple and cheap. An india-rubber cork accurately
fitting a strong bottle is perforated for two tubes each having a
stopcock. One of the tubes fits on the end at the exit in the basin,
and the other is adapted to an aspirating syringe.
[Footnote 315: _London Lancet_, vol. ii., 1879.]
[Footnote 316: Letter to author, 1883.]
One of the most important of the improvements to the aspirator-canula
is the addition--first suggested in 1858 by Charles Thompson,[317] and
afterward adopted by Potain, Powell, and Fraentzel--of a lateral tube
for the outflow connected with the main canula through which the trocar
passes. By this improvement, in case the canula is clogged up, the
trocar can be pushed down to remove the obstruction without danger.
[Footnote 317: _Med. Times and Gazette_, 1858.]
The principle of aspiration is now well established, and the
indications for its use are becoming more defined and more accurate.
New applications as a means of diagnosis, as well as of treatment,
daily render it more valuable.
To guard against the dangers shown by modern experience to be sometimes
attendant upon the operation of aspirating the pleura (see Dangers of
Thoracentesis), it is now generally admitted that the removal of the
contents of the chest should be slow and gradual; and that, ordinarily,
it is safest at one operation to remove only a portion of the effused
liquid. Our object should be to remove pressure and allow nature by
absorption to take away the remainder, for positive pressure is an
urgent indication for thoracentesis. It is therefore of primary
importance to properly estimate the quantity present, and thus to test
the intra-thoracic pressure. Great care and caution must be used,
because if we extract too much the operation may be followed by serious
results.[318] Large-sized canulæ should never be used, for fear of too
rapid withdrawal of fluid. It has been demonstrated that even with a
capillary perforated needle we can exercise more negative pressure than
is safe, especially toward the close of the operation, when there
supervenes a negative pressure exerted by the fluid remaining in the
pleural cavity. It is from these well-known facts that we recognize the
great value of Potain's ingenious addition to the aspirator of a
manometer of extreme simplicity, a kind of barometer or cuvette, which
is placed along the tube which withdraws the fluid. If we are not
satisfied with this new safety improvement of the aspirator, we may
adopt Douglass Powell's suggestion (_On Consumption, etc._) {597} of
fitting into the bottle a pressure-gauge, so as to know at any moment
what degree of aspiration is being used.
[Footnote 318: _Trans. de l'Assoc. pour l'Adv. des Sciences_, 6th
Session, 1877.]
The syphon method has been of late years very extensively used,
especially by Southey, W. H. Stone, and Garland, A. T. H. Waters,
Wilks, Oxley, and habitually by Douglass Powell. It is a feeble
aspirating force, which has very decided advantages. It is effective,
and acts slowly and uninterruptedly with a gentle and uniform negative
pressure. Its action allows the lung gradually to expand and the
displaced organs slowly to resume their normal position. It thus in
many cases furnishes us with a safe means of thoracentesis. (See
Surgical Treatment, in Pleurisy.)
{598}
{599}
DISEASES OF THE CIRCULATORY SYSTEM.
DISEASES OF THE SUBSTANCE OF THE HEART.
ENDOCARDITIS AND CARDIAC VALVULAR DISEASES.
CYANOSIS AND CONGENITAL ANOMALIES OF THE HEART AND GREAT VESSELS.
CARDIAC THROMBOSIS.
NEUROSES OF THE HEART.
DISEASES OF THE PERICARDIUM.
THE OPERATIVE TREATMENT OF PERICARDIAL EFFUSIONS.
DISEASES OF THE AORTA.
DISEASES OF THE CORONARY, PULMONARY, SUPERIOR MESENTERIC, INFERIOR
MESENTERIC, AND HEPATIC ARTERIES, AND OF THE COELIAC AXIS.
DISEASES OF THE VEINS.
THE CAISSON DISEASE.
DISEASES OF THE MEDIASTINUM.
DISEASES OF THE BLOOD, AND OF THE HÆMATOPOIETIC SYSTEM.
DISEASES OF THE BLOOD AND BLOOD-GLANDULAR SYSTEM.
DISEASES OF THE SPLEEN.
DISEASES OF THE THYROID GLAND.
SIMPLE LYMPHANGITIS.
{600}
{601}
DISEASES OF THE SUBSTANCE OF THE HEART.
BY WILLIAM OSLER, M.D.
Malpositions of the Heart.
We shall consider only such alterations as affect the whole organ;
faulty position of individual parts comes under the section upon
Malformations. It may, however, be mentioned that cases are known of
complete transposition of the chambers, the pulmonary artery and cavæ
being connected with the left, the aorta and pulmonary veins with the
right side, the valves being also transposed.[1]
[Footnote 1: Pazannuzzi, _London Med. Record_, 1877.]
Malpositions of the heart result either from errors of development, or,
more commonly, from changes in contiguous organs, usually the effect of
disease.
Of the congenital anomalies only a few are of practical interest. The
heart may be placed vertically in the chest, as in the foetus, the apex
beating at the lower end of the sternum; or, more rarely, the organ
lies transversely. Dextrocardia, the condition in which the heart is on
the right side of the body, is much more important, and is usually
associated with the transposition of the abdominal viscera--situs
inversus viscerum. In these cases the apex-beat is in the region of the
right nipple; a distinct area of dulness can be obtained to the right
of the sternum, in which situation the heart sounds are loudest; and,
lastly, there is pulmonary resonance in the place of normal cardiac
dulness. In the great majority of cases--70 out of 78[2]--the abdominal
organs are also transposed, the liver on the left side, the spleen on
the right; but in a few instances the heart alone has been misplaced,
and under such circumstances care is needed to diagnose the condition
from dislocation of the organ due to old-standing lung disease with
retraction.
[Footnote 2: Gruber, _Virchow's Archiv_, 1865.]
More serious congenital malpositions, but of less practical importance,
are the cases of ectopia cordis, which may exist in all grades, from
simple failure of closure in the sternum--fissura sterni--to the most
extreme condition, in which the naked heart lies outside the
chest-wall. Hodgen[3] and March[4] have each described remarkable
examples of the latter condition. In other instances the heart lies
free in the neighborhood of the neck, or it may be in a congenital
umbilical hernia.
[Footnote 3: _American Practitioner_, xviii. p. 107.]
[Footnote 4: _Trans. of the New York State Medical Society_, 1859.]
The malpositions with which we are more immediately concerned arise
from disease of the heart itself or its membranes, or from disease of
contiguous organs.
We judge of the situation of the heart by the site of the apex-beat, by
the position and extent of the area of dulness, and by the character of
the sounds. So constant in health is the position of the apex-beat in
the fifth intercostal {602} space that in our examination of the heart
we seek first to determine its existence as affording the most
important information of the normal situation of the organ. The area of
dulness is a much more variable guide, depending as it does so greatly
on the degree of distension of the lungs. When, as sometimes happens,
neither apex-beat nor area of dulness can be obtained, the position of
maximum intensity of the heart sounds becomes an important indication.
In regard to the effect of respiratory movements in the position of the
heart, with each inspiration it is drawn down slightly by the descent
of the diaphragm, and it is separated from the chest-wall by the
inflation and descent of the left lobe of the lung--in deep inspiration
to such a degree as to obliterate the area of dulness and to prevent
the systolic impulse from reaching the intercostal space.
The effect of gravity on the position of the heart is well illustrated
by the more forcible and extended beat when the chest is bent forward
or when the person is turned toward the left side--procedures
frequently resorted to when from any cause the apex-beat is obscure.
Of diseases of the heart itself, dilatation and hypertrophy are very
common causes of displacement, and in general enlargement the organ may
occupy a very considerable part of the left side of the chest, and the
apex-beat in the seventh or eighth space in the axillary line.
Hypertrophy of the left ventricle alone pushes out the apex-beat, while
enlargement of the right ventricle gives a stronger impulse toward the
left border of the sternum and a more marked pulsation below the
ensiform cartilage. Hypertrophy and dilatation of the auricles increase
the width of the cardiac dulness, and may cause marked pulsation in the
second and third spaces on either side of the sternum.
In pericardial effusion the heart is pressed backward and the apex
slightly raised.
To understand clearly the effects upon the position of the heart of
disease of contiguous organs, we must bear in mind their mutual
relations. Situated in the mediastinum between the lungs on either
side, it is subject to the elastic traction of these organs, which
counterbalance each other, but if from any cause the elastic tension of
one lung is suppressed, as in pneumothorax or in pleural effusions,
then the other lung may also collapse to a slight degree, and pull over
the mediastinum and with it the heart. The pericardium is firmly fixed
below to the diaphragm, chiefly to the central tendon, to a slight
extent also to the muscular substance, but the union with the diaphragm
is so intimate that there can be but little movement of the attached
portion. The mobility of the heart is measured by that of the
mediastinum and pericardium, and through these alone the displacing
forces act. The limits of dislocation are determined by the attachments
of the central tendon, of the inferior cava, and the great vessels at
the root. Within the pericardium the heart has a certain degree of
mobility, but this is confined, as regards pressure or traction
effects, to rotation upon its axes.
Of the malpositions due to changes in contiguous organs, the following
may be considered:
Changes in the Chest-wall.--The gradual incurvation of the ribs and
costal cartilages in some cases of rickets may alter the position of
the heart.
Curvature of the spine, particularly cases which narrow to a great
extent the upper outlet of the thorax, may produce very considerable
displacement of heart and great vessels. There may be areas of
extensive pulsation on either side of the sternum, and the condition
may simulate aneurism of the aorta, as in a case reported by
Bramwell.[5]
[Footnote 5: _Lancet_, 1878, i.]
In certain affections of the lungs the position of the heart is much
altered. {603} In emphysema, when extensive, the apex is directed more
to the right, and the organ is somewhat lower than normal, on account
of the depressed condition of the diaphragm. The heart may also occupy
a more transverse position. The area of cardiac dulness may be greatly
reduced by the distended left lung, and there is usually forcible
epigastric pulsation, due to the lower position of the organ and the
hypertrophy of the right ventricle which almost always accompanies
emphysema.
The most marked displacement is produced by fibroid induration of the
lung, with contraction--cirrhosis. As the process of condensation goes
on, the chest-wall is gradually flattened, and the mediastinum, with
the heart, drawn toward the affected side. When the left lung is
involved, the heart may be completely to the left of the median line,
and is usually drawn upward as well. There may in such cases be a very
wide area of impulse, as the heart occupies the position of the left
lung in front. In cirrhosis of the right lung the organ is drawn toward
the right side, and the area of visible impulse may be in the third and
fourth interspaces to the right of the sternum. In the process of slow
traction the heart revolves upon itself and the left chambers come
uppermost. In many cases of chronic phthisis, when the anterior margin
of the left lung is involved, the retraction from induration may leave
a large portion of the heart exposed and increase the area of visible
pulsation; sometimes, when there is much contraction of the upper lobe,
the organ is drawn up and to the left, and the apex-beat may be in the
fourth interspace.
The pressure of a pneumonic lung may depress the diaphragm and draw
down the heart.
Abnormal conditions of the pleuræ are frequent causes of cardiac
displacements. In pneumothorax there is collapse of the lung on the
affected side, and the elastic traction of the sound lung draws over
the mediastinum and heart. It is not that the heart is pushed over, as
so often stated, but the tension of the other lung, being unopposed,
pulls the mediastinum toward the sound side. Later, when, as usually
happens, effusion takes place, the pressure assists in the
displacement. In pleuritic effusion dislocation of the heart to one
side is almost constant if the amount of fluid is at all considerable.
Here pressure plays the most important part, and the heart is gradually
pushed over by the effusion; but the elastic tension of the lung on the
sound side is also concerned in the result. In right-sided effusion the
whole organ may be to the left of the median line, and from the
depression of the diaphragm it is usually lower in the chest, so that
the apex-beat may be in the sixth, rarely the seventh, interspace in
the axillary line. When the exudation is on the left side, the
dislocation is more marked, and there may be a cardiac impulse at the
right nipple or even beyond it. A common error is to regard the
pulsation as due to the apex, but it is invariably caused by some
portion of the right chambers, usually the ventricle. Even in the most
extensive effusion the apex is probably never pushed beyond the right
border of the sternum, and the relative position of apex and base is
not changed. This I have carefully noted in several autopsies.[6]
[Footnote 6: Fig. 76 of Sibson's article on "Displacements of the
Heart" in _Reynolds's System of Medicine_ gives an incorrect idea of
the position of the organ in these cases, as the apex is represented as
beating beneath the right nipple.]
In the gradual absorption of a pleuritic effusion, serous or purulent,
the heart may not only regain its normal position, but is in many
instances drawn toward the affected side by the contracting false
membranes.
Of conditions of the mediastinum producing displacement, two only need
be mentioned--aneurism and tumor. Very large aneurisms of the arch
usually press the heart downward, and its axis may be transverse; but
much depends on the direction of growth, and a slight lateral and
downward dislocation is most frequently met with. Tumors do not
necessarily {604} cause displacement, but when large there may be some
dislocation in the direction of the growth of the mass. Most extensive
masses of mediastinal cancer may occur without any disturbance of the
position of the heart.
Diseases of the abdominal viscera not uncommonly produce dislocation of
the heart, generally upward. Extensive peritoneal effusion, gaseous or
fluid, forces up the diaphragm, and with it the heart, which may assume
the transverse position, and the apex beat as high as the third
interspace. Gas much more readily than fluid rapidly lifts the
diaphragm and produces upward dislocation of the heart. Diaphragmatic
hernia of intestines or stomach may push the heart up or to one side.