ASPIRATION IN PERICARDIAL EFFUSIONS.

BY JOHN B. ROBERTS, M.D.,

PENNSYLVANIA.

THIS subject seems a proper one to bring before the Association, since patients undoubtedly have died, and probably still die, every year, because the attendant is too timid to thrust an aspirating needle into the pericardium, to relieve the heart of the hydrostatic pressure which threatens to prevent its lifesustaining pulsations. The operation of tapping the pericardium was proposed over two hundred years ago, and yet how few instances of its performance have been recorded! I cannot believe that large pericardial effusion is as uncommon as these cases would seem to indicate. Rheumatism and thoracic inflammations, the great factors in the etiology of pericarditis, are too frequent among us to allow any other explanation of this fact than that pericardial effusions are treated only by medical means, and abandoned if absorption is not accomplished.

When tapping the chest in cases of pleuritis with effusion was introduced, it was the custom to wait many weeks before using operative means for withdrawing the fluid; and many autopsies showed the results of this protracted delay by thickened pleuræ, compressed and useless pulmonary tissue, and perhaps even fistulæ, showing the attendant that nature had done what he had been afraid to attempt. In course of time we learned to recog nize the value of paracentesis of the chest, and improved instruments gave it a wider field. Doubtless a similar history will be told of tapping the pericardium, as soon as the profession shakes off the feeling that the heart and its covering will not bear operative interference, and learns that the operation is much less serious than the retention of a large amount of fluid within the pericardial sac.

The causes of pericarditis are too well known to all to require more than a passing notice at this time, and it would perhaps be considered presumptuous in me to attempt to instruct you in the symptomatology, physical examination, and diagnosis of effusion in the pericardium. I shall, however, sketch briefly the main points concerning these topics, in order to bring my subject systematically before you. Pericarditis as a complication of rheumatism is often seen by all of us, though it is not usual for it to assume characteristics of great gravity. Occasionally the fluid effused increases rapidly, and the oppression resulting may terminate fatally. It is in such cases that the most brilliant results have followed tapping, because the distended sac is immediately relieved of its contents, and the primary disease is one of favorable prognosis. Again, pericarditis may occur from the extension of pulmonary inflammations, when the prognosis is rather less favorable than in the former instance. Any condition liable to favor the transudation of serum into the cellular tissue and cavities of the body may be the exciting cause of hydro-pericardium; especially is this the case in chronic disease of the kidneys.

The symptoms of dropsy of the pericardium are of little value, and we have to rely upon physical exploration to make out the diagnosis. The increased dulness, the feebleness of the heartsounds and apex-beat, and the frequent presence of a frictionmurmur suffice, as a rule, to establish the character of the lesion. At times, however, the differential diagnosis between a feeble, dilated heart and a pericardial effusion becomes a matter of considerable difficulty. Very fortunately, in the vast majority of patients the diagnosis can be established, after a careful physical examination has been instituted.

It has recently been asserted that dulness in the fifth intercostal space an inch or an inch and a quarter from the right edge of the sternum is a distinctive sign of pericardial effusion, as opposed to any form of cardiac enlargement.

With these prefatory remarks, I shall enter upon the consideration of paracentesis of the pericardium itself, discussing the methods of operating, the best point of puncture, the kind of cases to which tapping is adapted, and, finally, the results which have been obtained.

There is little probability of any dissenting voice, when I say that the best method of puncturing the sac is by aspiration.

An ordinary trocar has been used, and some of the older operators preferred to dissect through the integumentary and muscular layers until the distended pericardium was reached, but this is not as satisfactory as thrusting an aspirating trocar or needle directly through the thoracic wall. The tough integument may be incised first, and the skin drawn down before the needle is introduced. The vacuum chamber ought to be attached to the needle as soon as its point is buried, in order that the flow of serum may tell when the pericardial fluid has been reached. Otherwise the instrument might be thrust onward into the right ventricle, for the thoracic wall is not thick. The best form of puncturing instrument is Fitch's dome-shaped trocar, with the necessary attachment for the aspirating pump.

There have been suggested several points for puncturing the pericardium, but the best, I believe, after numerous experiments and measurements, is in the fifth intercostal space, about five centimetres to the left of the median line of the sternum. This may require some modification in small children, and in instances where pericardial adhesion at that point is suspected. The internal mammary artery runs parallel to the border of the sternum, about a quarter or half inch from it, and must be avoided. The auricle of the heart is in danger, if the needle be introduced through the upper spaces, and if a point too far to the left be selected, there is, as shown by my experiments, danger of passing outside of the left wall of the sac. A puneture in the sixth space might enter the abdomen, after piercing the edge of the diaphragm.

The pleura must in most cases be wounded, because it is reflected over the pericardium from the costal cartilages; hence the aspirating needle penetrates both layers of pleura before it enters the pericardium. In chronic purulent pericarditis there is very probably adhesion here, which is of value, as it precludes the possibility of the pus escaping into the pleural cavity. A small puncture is of importance in all cases for the same reason. As it, therefore, seems hardly possible to avoid puncturing the pleura, the object to be avoided is the mammary artery mentioned above; hence the needle should be introduced between the artery and the nipple. A point well chosen, as stated above, is in the fifth space, about two inches from the middle line of the sternum, which, by the way, is more readily determined than the left edge of the bone, since the tissues prevent accurate de

termination of this border. The operator must also recollect the fact that the intercostal spaces become narrow as they approach the sternum, and that the cartilages of the lower ribs are inclined obliquely upwards. Unless these anatomical points are thought of, the needle may be thrust into the cartilage and a second selection of a place for operation be necessitated.

You may ask what cases are suitable ones for paracentesis pericardii. The reply to this question is, that in all cases of pericardial effusion in which medication has failed to relieve the heart by reducing the quantity of fluid, and in which grave symptoms supervene, the aspirator should be resorted to at once. This should not be delayed until the patient is worn out, the lungs engorged, and the pericardium converted into a pyogenic membrane, but should be thought of, as it is in pleural effusion, as soon as the inadequacy of drugs is evident. The most brilliant results are obtained in cases in which sudden serous effusion of great amount has occurred in articular rheumatism; here the withdrawal of the fluid averts all danger, and the patient recovers from his rheumatic fever in a few weeks. When there is Bright's disease, chronic pleuro-pneumonia, or purulent pericarditis, it is not to be expected that the success obtained will be so perfect.

It should be remembered, moreover, that renal symptoms may be produced by the kidney congestion caused by the embarrassed heart, and that removal of the pericardial effusion may induce disappearance of the albuminuria.

When the fluid reaccumulates the aspirator should be again resorted to, and if the effusion becomes purulent a drainage tube or canula may be left in the wound. I see no reason why disinfectant solutions should not be employed at times to wash out the pus, though probably this would rarely be necessary.

Finally, let a brief survey be taken of the results of pericardial tapping. The early cases collected in my monograph, recently published, are meagre in detail; and of the diagnosis of some there is reason to doubt the authenticity. Hence I shall

This question will be found fully discussed in my monograph entitled "Paracentesis of the Pericardium: A Consideration of the Surgical Treatment of Pericardial Effusions." Philadelphia: J. B. Lippincott & Co., 1880. 2 Paracentesis of the Pericardium. Philadelphia, 1880.

3 Hindenlang also gives a number of early cases. See Deutsches Archiv für Klinische Medicin, 1879.

speak of the cases operated upon in the last twenty years, of which we are able to obtain more accurate information. Taking the cases in the monograph mentioned, with the new ones in the subjoined table, I have 42 cases of paracentesis performed since 1860. Of these there were, recoveries, 14; deaths, 28; total, 42. This gives a mortality of 663 per cent., which does not seem high, when it is recollected that in all but three of the 28 fatal cases serious complications are mentioned as present. One would not expect to obtain complete recovery by aspirating the pericardial effusion, when incurable disease of lungs, heartvalves, or other viscera existed. Moreover, I have purposely included in the deaths some cases that have lived several weeks after the aspiration, and, therefore, certainly did not die as a result of the tapping; but as they died during the continuance of symptoms for which the pericardial aspiration was performed, it was deemed proper to place them in the death column. That paracentesis of the pericardium is beginning to take its proper place in practical surgery is evinced by the fact that only a few years ago there appeared to be recorded but one authentic case. of the operation in America, while now I have records of no less. than twelve instances. Nearly all of these have occurred in the last few years, and, of the twelve, five have recovered and seven have died. This gives a mortality in the American cases of 58 per cent.

In future the operation will doubtless be attempted at an earlier period of the treatment, and many lives saved that in former years would have been sacrificed by procrastinating timidity.