received a new impetus within the last fifteen or twenty years from the
investigations of Trousseau,[1] Roberts,[2] Hindenlang,[3] Fiedler,[4]
West,[5] and others. Reference to the works of these writers will
furnish the reader with the history and statistics of such operations,
and with those details that I have not deemed necessary to incorporate
in the present article.
[Footnote 1: _Clinical Medicine_.]
[Footnote 2: _New York Med. Journ._, Dec., 1876, with analysis of 41
cases; also _Paracentesis of the Pericardium_, Philada., 1880; _Trans.
Am. Med. Ass'n_, 1880; and elsewhere.]
[Footnote 3: _Deutsches Archiv für klinische Medicin_, 1879.]
[Footnote 4: _Samml. klin. Vortr._, No. 215, Leipzig, 1882.]
[Footnote 5: _Medico-Chirurgical Transactions_, 1883.]
In all cases of bloody, serous, purulent, or aërial effusions into the
pericardium, that present dangerous symptoms of heart failure,
operative interference should be undertaken as soon as it is evident
that medication is not lessening the embarrassment of the central organ
of circulation. It is bad practice to delay the operation, which will
generally be aspiration, until exhaustion, pulmonary engorgement,
pericardial changes, and degeneration of the cardiac muscle render
permanent relief impossible. The tendency is to wait, instead of
affording immediate relief of the distressing symptoms by prompt resort
to pericardicentesis. Clinical experience has abundantly shown that
when the pericardial fluid is evacuated, dyspnoea, cyanosis,
irregularity of the pulse, and the other threatening symptoms are
lessened; and usually at once.
The time for aspiration depends less on the amount of fluid than would
at first be supposed, because the sudden effusion of a moderate amount
of serum will exert more pressure upon the heart than a much larger
quantity poured out in so gradual a manner as to allow the pericardium
to become stretched. Aspiration should therefore be performed in all
cases of pericardial effusion, in which dangerous symptoms of heart
embarrassment occur, as soon as medication fails, and without regard to
the supposed quantity of fluid. This should be the practice without
regard to any other visceral lesion that may be present as a
complication, except in the case of pleural effusion.
When pleural effusion of considerable amount coexists, the pleural sac
should be aspirated first, because of the difficulty of discriminating
between respiratory distress due to pulmonary pressure and that
resulting secondarily from interference with cardiac action, and
because the evacuation of the pleural effusion seems at times to lead
to absorption of the fluid in the {795} pericardium without resort to
operation. This rule applies to pleurisy of the right side as well as
of the left.
In dropsy of the pericardium from renal disease I admit that the
transudation is at times absorbed with great rapidity, and that
aspiration does not directly affect the primary disease; but still,
tapping should be done if the failure of circulation and respiration
seems to be dependent on the effusion. Pepper's case[6] of recovery
after pericardicentesis affords corroborative evidence of the propriety
of this advice. Before operation the urine was albuminous and contained
tube-casts, but these symptoms entirely disappeared in the course of a
few weeks.
[Footnote 6: _Medical News and Library_, Philada., March, 1878; and
_Am. Journ. Med. Sciences_, April, 1879.]
When the amelioration of symptoms following the operation is not
permanent because reaccumulation takes place, repetition of the
operative procedure is demanded. It is better, in my opinion, to vary
somewhat the point of puncture, lest the heart be wounded at the second
tapping because of adhesion of the parietal to the visceral pericardium
at the original point of puncture. Should repeated tapping be required
in serous effusions, I should at the time of the third operation inject
into the sac, after removing the serum, a solution containing tincture
of iodine, alcohol, or carbolic acid, with the purpose of modifying the
secreting surface and producing pericardial adhesion. Universal
pericardial adhesion has been found by examination subsequent to cure
by aspiration; and in a number of cases intra-pericardial injections
have been made without preventing, or apparently interfering with,
recovery.
The fluid injected ought probably to be concentrated, as the object to
be obtained is pericarditis of a grade that will furnish plastic
exudation instead of serum. Undiluted but liquefied carbolic acid, such
as is used in treating hydrocele of the vaginal tunic of the testicle,
would be the proper agent were it not for the possibility that its
contact with the heart-walls might induce dangerous cardiac spasm. The
strength of the fluid to be injected, as well as its utility, will have
to be determined by future observation. Aran used fifteen grammes of
tincture of iodine (French), one gramme of iodide of potassium, and
fifty grammes of distilled water, and his patient recovered. Malle
injected a solution of tincture of iodine "five times weaker than that
recommended for hydrocele operations," but suspended the operation
quickly because of the excessive pain in the cardiac region produced by
the injection. Violent inflammatory symptoms arose. The patient died of
diarrhoea before the exact result of the injection could be determined,
though the indications were that cure by pericardial adhesion was about
to take place. The autopsy seemed to confirm this belief.[7] It must be
remembered also that his operation was done by trephining the sternum,
which may have had something to do with the inflammatory reaction,
though the injection was not made until the sixteenth day after the
original operation.
[Footnote 7: _De la Paracentèse du Péricarde_, par Michel Labrousse,
Thèse No. 107, 1871, pp. 22, 27.]
When aspiration has shown the pericarditis to be purulent, a free
incision should be made, an antiseptic drainage-tube of good size
introduced, and the cavity washed out daily with antiseptic solutions
of carbolic acid (1 to 40) or corrosive sublimate (1 to 2000). In fact,
pericardial effusions should be managed exactly as pleural effusions by
tapping, injection, or drainage, according to the character of the
contents of the sac. I have advocated this course since 1876, and it
has been justified by the cases of Villeneuve, Jürgensen, Viry,
Rosenstein, West, Partzevsky,[8] and Savory. Although these operators
did not all practise free incision, yet the study of their cases shows
the absence from danger and the propriety of such incision. As far as I
{796} know, no cases of purulent pericarditis have recovered after
simple aspiration. The case of Rosenstein and that of West, however,
did recover after incision and drainage; and in that of Villeneuve,
which was originally serous, there remained a fistulous track
discharging pus for nearly six months, when spontaneous closure and
cure resulted. Gussenbauer has successfully treated pyopericardium
following acute osteo-myelitis at the shoulder by resection of five
ribs and washing out the sac with a thymol solution.[9]
[Footnote 8: See _Lond. Med. Rec._, Feb. 15, 1883.]
[Footnote 9: _Wien. med. Wochenschr._, Nov. 21, 1884, quoted in
_Medical News_, Philada., Jan. 17, 1885.]
Pericardial fistules, due to spontaneous or operative evacuation,
should be managed by dilatation, with compressed sponge, and irrigation
of the cavity with astringent or disinfectant solutions. Some supposed
pericardial fistules may be pleural fistules, or sinuses opening into
small pockets between the parietal and visceral layers of an adherent
pericardium, or entirely external to the pericardium in new tissue
occupying the mediastinum. Such sinuses should be laid open with the
scalpel, and compelled to granulate from the bottom. Sinuses dependent
upon diseased rib, sternum, or cartilage should be laid open, and the
necrotic or carious structure removed by burr or chisel.
Incision of the pericardium under antiseptic precautions may be useful,
and is justifiable as a diagnostic procedure in grave cases when doubt
exists between a large pericardial effusion and a dilated heart. The
wound will scarcely increase the danger if the pathological condition
be cardiac dilatation, and may save life if effusion be the cause of
the threatening symptoms. The case of Vigla upon which Roux operated
shows the value of such procedures.[10]
[Footnote 10: Trousseau's _Clinical Medicine_.]
Aspiration is the method to be employed at first in all instances of
pericardicentesis. Incision is to be reserved for the second step in
purulent pericarditis, for diagnostic purposes, and for the extraction
of foreign bodies, and similar operative designs. The best point for
aspiration is usually in the fifth interspace, just above the sixth
rib, and about five or six centimeters (2-2¼ inches) to the left of the
median line of the sternum. In a child it should be a little nearer the
sternum. The point advised is outside of the line of the internal
mammary artery, is in a wide portion of the intercostal space,
corresponds with the notch in the border of the left lung, is low
enough to preclude wounding the auricle, high enough to avoid the
diaphragm, and does not approach the point where a cartilaginous band
often joins the fifth and sixth costal cartilages. Both layers of the
pleura will probably be pierced by the aspirating-needle at this point,
but this is not an important complication, and can only be avoided with
anything like certainty by going close to the sternum, which is
objectionable on other grounds.
The aspiration may be performed by using the pump and the ordinary
needle or trocar which is furnished by instrument-makers in the
aspirator-case. In cases of emergency or for mere exploratory puncture
the common hypodermic syringe and needle will answer the purpose. The
puncturing instrument should be clean and anointed with carbolized oil,
and in all cases the vacuum-chamber should be attached to the needle or
trocar as soon as its point is buried beneath the skin, in order that a
flow of fluid may indicate the moment at which the pericardial sac is
entered. Abrasion of the heart, which may occur from contact with the
needle-point when the fluid is almost entirely evacuated, is not very
important, but should be avoided if possible by deflecting or partially
withdrawing the needle, or by using Roberts's improved pericardial
trocar or that suggested by Pepper. The instrument figured in my
monograph on _Paracentesis of the Pericardium_ was too large {797} for
use. The improved instrument here figured is no larger than a
moderate-size aspirating-needle. It consists of such a needle,
flattened at its upper extremity to give the surgeon a firm hold,
within which slides a canula. The distal end of the canula, made
flexible by a spiral, when thrust beyond the point of the needle curves
downward, and thus prevents the point of the puncturing instrument
injuring the heart when the sac is nearly emptied. During penetration
of the thoracic wall the canula is retracted, so that the flexible end
is contained within the needle, and the perforation at the end of the
canula allows the fluid to escape as soon as the sac itself is
punctured. The canula is then thrust forward until the sharp point of
the needle is guarded. This movement brings a lateral fenestra in the
canula opposite a similar opening in the needle, and thus provides a
second orifice for the escape of fluid in case the terminal one becomes
occluded. The external end of the canula has a square shoulder to
prevent rotation within the needle, and should be tight enough at that
point to preclude entrance of air. The canula finally terminates in a
ground end for attachment to the aspirator-tube. The needle--or outer
canula as it may be called--is marked on the surface to show the number
of centimeters concealed in the tissues. If the inner canula is
suspected to be clogged with shreds of lymph or with thick pus, it can
be withdrawn without disturbing the needle. The attachment may then be
made to the latter as if it were an ordinary aspirating-needle, or the
inner tube being cleaned may be reinserted. This is an important
element, gained by using a double aspirating-trocar; for plugging is
not uncommon in pericardicentesis done for chronic inflammation of the
sac.
[Illustration: FIG. 49. Roberts's Pericardial Aspirating Trocar.]
Beverley Robinson of New York has still further modified[11] my trocar.
His additions may have improved the instrument if they do not unduly
complicate it. Pepper, after operating upon his case, had made a
delicate double canula, the inner tube of which was furnished with a
fine needle-point. After introduction the inner tube was withdrawn
until its point was sheathed.[12]
[Footnote 11: _New York Med. Record_, March 29, 1884.]
[Footnote 12: _Medical News and Library_, Philada., March, 1878.]
It is said that at the meeting of the Italian Medical Association at
Pisa in 1878, Baccelli proposed a new method of puncture; but the
account given by Severi[13] in speaking of Baccelli's cases indicates
that his proposal referred not to a method of operating, but to a
method of selecting the point of puncture.
[Footnote 13: _Lo Sperimentale_, Aprile, 1881, p. 392.]
It must also be remembered that failure to obtain fluid when
pericardial effusion existed has occurred because the needle had been
passed through a costal cartilage, and was thus plugged by a disk of
cartilage. The manner in which the intercostal spaces are narrowed and
changed in direction by the curving upward of the anterior portion of
the ribs and by the curvature of the cartilages should be impressed
upon the operator.
If failure to obtain fluid occurs, and the diagnosis remains quite
certain from the symptoms, withdrawal of the needle and puncture in
another position should be done or an incision of an exploratory kind
made.
{798} In pericardicentesis care must be taken not to thrust the needle
or trocar into the heart. This may happen even in quite careful hands.
If the right ventricle is entered, venous blood will escape through the
canula; if the needle is buried in the cardiac muscle, no fluid or
blood can escape. The violent movements communicated to the needle will
usually indicate that the needle is either in contact with the heart or
thrust into its tissue. Of course such movements will occur from
cardiac contact when most of the fluid has been withdrawn; but are not
to be expected immediately after the introduction of the puncturing
instrument unless the fluid is very small in amount, the needle deeply
inserted, the pericardium adherent at the point of puncture, or the
diagnosis of fluid an error.
Puncture of the heart has occurred accidentally during pericardial
tapping without doing any harm, and has been suggested as a proper
surgical procedure in certain cardiac conditions. Still, it is an
accident to be avoided by the use of proper trocars and pumps, by the
selection of a proper site of operation, by the adaptation of the
suction power as soon as the point of the trocar or needle is buried
beneath the skin, and by other precautions that will suggest
themselves. In thick, oedematous, or fatty chest-walls no fluid will be
reached perhaps until a depth of four or five centimeters (about two
inches) has been attained by the point of the puncturing apparatus.
I must call attention to the fact that West[14] records a case of
pericardial tapping occurring at St. Bartholomew's Hospital in 1874
where a trocar and a canula were introduced through the fourth left
space near the edge of the sternum, and caused death in five minutes
from hemorrhage into the pericardium, due to tearing of the right
ventricle. The position chosen and the form of instrument may have had
to do with this unfortunate result, of which the details are not given.
[Footnote 14: _Med.-Chir. Trans._, 1883, pp. 259, 275.]
A few words on cardicentesis, or intentional heart-puncture, may here
be appropriate. It has been suggested as a means for rapid abstraction
of blood from the right heart in intense pulmonary and cardiac
engorgement, and for the abstraction of air after air-embolism has
occurred from wounds of the large venous trunks. It has been known for
years that aspiration and similar punctures of the heart are
comparatively harmless. Roger accidentally withdrew 200 grammes of
blood from the right ventricle of a boy of five years without doing
harm. Hulke seemed to benefit a case of pleuro-pneumonia by
accidentally aspirating the right heart. Cloquet, Bouchut, Steiner, and
Legros and Onimus have made similar observations on the absence of
danger from such wounds. Westbrook of Brooklyn, Corwin,[15] Dana,[16]
and apparently Janeway of New York, have performed intentional cardiac
aspiration in moribund patients without causing any noticeable harm.
The contributions of Westbrook,[17] Roberts,[18] and Leuf[19] on this
topic, as well as that of Senn[20] on air-embolism and its treatment,
will interest those who wish further information.
[Footnote 15: _N.Y. Med. Record_, March 10, 1883, p. 263.]
[Footnote 16: _Ibid._, Feb. 3, 1883, p. 140.]
[Footnote 17: _Ibid._, Dec. 23, 1882.]
[Footnote 18: _Philada. Med. News_, Jan. 13, 1883.]
[Footnote 19: _Amer. Journ. Med. Sci._, Jan., 1885, p. 79.]
[Footnote 20: _Trans. Amer. Surg. Ass._, 1885, and _Annals of Surgery_,
St. Louis, 1885.]
* * * * *
The results of operations for pericardial aspiration or incision are
exceedingly good when the frequent postponement of the operation till
the patient is almost moribund is recollected. Elaborate statistical
tables would be out of place in this volume; and, besides, it seems
almost impossible to get a complete collection of the cases.
Hindenlang, West, and I have published {799} and analyzed long lists of
cases collected from various sources, and I have now references to
more, but this tabulation seems unnecessary, as the practical points to
be derived from their study are well proved by the previous work done.
In addition to the bibliographical notes already given, I add for the
use of inquirers in this field two recent monographs--one by a
German,[21] the other by a French writer.[22]
[Footnote 21: _Ueber Paracentese des Herzbeutels_, Gerhard Beck,
Würzb., 1882, p. 33 (Thesis).]
[Footnote 22: _Contribution à l'Étude de la Paracentèse du Péricarde_,
H. Ferraud, Bordeaux, 1883.]
{800}
DISEASES OF THE AORTA.
BY G. M. GARLAND, M.D.
Acute Aortitis.
The existence of inflammation of the membranes of the aorta was
mentioned by Galen and other early writers, but it was not until 1824
that a systematic treatise on this subject was published. Since that
time the subject has received more attention, but the results obtained
are unsatisfactory. There is grave doubt, according to many writers, as
to the existence of acute aortitis independent of other lesions,
although it is recognized that the aorta may participate in
inflammation of the neighboring organs. Even then, as Powell says, "the
aorta is very slow to share in such processes, and when it does so the
inflammation is very chronic and limited, giving rise to no special
symptoms." Peter treats the subject at length, and after enumerating
certain so-called symptoms of acute aortitis, confesses that these
symptoms are merely the ordinary phenomena of angina pectoris, and
these two affections cannot be distinguished from each other. It must
be concluded for the present, therefore, that acute aortitis is rare,
and that we know of no symptoms which are characteristic of it.
Atheroma of the Aorta.
Atheroma of the aorta is the result of chronic endarteritis, and is
always of slow development. The process may be limited to the intima or
it may extend to the middle and outer tunics. Beginning with a
thickening and softening of the wall, it finally develops plates of
calcareous deposit. These plates are most numerous in the region of the
aortic valves, and diminish in number as the artery proceeds from that
point. The descending portion of the aorta is relatively free from
these patches, but they reappear again near or at the bifurcation.
ETIOLOGY.--Atheroma is one of the ordinary products of old age, and is
therefore one expression of senility. Heredity probably exerts some
influence, and certain cachexias predispose to an early occurrence of
the process. Gout and syphilis render one especially prone to it. High
pressure and strain are also important factors. Continuous hard toil is
more productive of atheroma, according to Allbutt, than intermittent
work. The pre-albuminuric stage of Bright's disease, which is
characterized by high arterial pressure, is frequently productive of
atheroma.
SYMPTOMS.--When the inner coat alone is affected, there are no symptoms
of this disease. According as the degeneration extends deeper and
involves the middle and outer tunics, the aorta begins to dilate, and
the symptoms may vary from the slightest feelings of discomfort upon
exertion to the most violent attacks of palpitation and pain.
{801} Usually, at the beginning the symptoms are very obscure. A slight
dyspnoea on exertion, or palpitation, or dyspeptic troubles are the
chief complaint. The presence of these troubles in a man of fifty years
or over, whose heart and kidneys present nothing abnormal, and in whom
the smaller arteries of the extremities feel hard and calcareous, may
excite the suspicion of atheroma of the aorta. There are no distinctive
physical signs. Some writers speak of a short post-systolic murmur over
the aorta beyond the valves, which may be audible only when the heart
is acting strongly.
The aorta is almost invariably dilated, and Peter says that this
dilatation may be traced by percussion. According to him, the normal
aortic dull area measures from two to five centimeters transversely in
the male, and from two to four centimeters in the female. He says that
he has seen cases of atheroma where he was able to determine a dull
aortic area of eight centimeters in diameter. If the inflammation
extend from the aorta to the neighboring nerves, the patient may suffer
from the ordinary symptoms of angina pectoris.
TREATMENT.--This disease cannot be cured by drugs. The physician's task
is to regulate the habits of the patient, to remove so far as possible
all conditions which tend to aggravate and increase the trouble, and to
alleviate incidental symptoms of distress.
Thoracic Aneurism.
DEFINITION.--The origin of the term aneurism is buried in obscurity,
and the theories which have been advanced regarding it are not very
satisfactory. Montanus thought it was derived from _a_ privative, and
_neuron_, a nerve. Oetius declares it is from _aneurisma_, an
enlargement, from _eurumo_, I dilate. Coale thinks a ready origin is
offered in the words _aneu_, without, _rusmos_, a series, course, or
succession, from _ruo_, I flow.
Aneurism of the aorta is a local dilatation of that vessel. When all
the arterial tunics persist unruptured in the tumor, it is a true
aneurism. When one or more of the tunics are torn in the process of
expansion, it becomes a false aneurism. When all the tunics of the
artery rupture and the blood escapes into the neighboring cellular
tissue, it becomes a diffuse false aneurism. The internal and middle
coats of an artery may burst, and the blood escape into and coagulate
in the space between the middle and external tunics, and this is termed
a dissecting aneurism. In rare instances of this type of aneurism the
blood finds a second opening, and returns into the artery again, thus
forming a double tube for a short distance.