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PARACENTESIS 
 
 THE PERICARDIUM. 
 
PARACENTESIS 
 
 OP 
 
 THE PEEICAEDIITM, 
 
 A CONSIDERATION OP THE 
 
 SURGICAL TREATMENT 
 
 OF 
 
 PERICARDIAL EFFUSIONS. 
 
 BY 
 
 JOHN B. ROBERTS, A.M., M.D., 
 
 LECTVRER ON ANATOMY IN THE PHILADELPHIA SCHOOL OF ANATOMY; DEMONSTRATOR OF 
 
 ANATOJttY IN THE PHILADELPHIA DENTAL COLLEGE; FELLOW OP THE 
 
 PHILADELPHIA ACADEMY OF SURGERY. 
 
 WITH ILLUSTRATIONS. 
 
 PH ILADELPH I A : 
 
 J. B. LIPPINCOTT & CO. 
 
 London : 16 Southampton Street, Covent Garden. 
 188 0. 
 
Copyright, 1879, by John B. Roberts, M.D. 
 
PREFACE. 
 
 Several years ago, while resident physician and sur- 
 geon in one of the hospitals of Philadelphia, I endeavored 
 to occupy my spare hours profitably in the library of the 
 institution. Among the subjects that attracted my atten- 
 tion was that of tapping the pericardium. Although I 
 found recorded a number of isolated instances of the 
 operation, there were few general deductions made, and 
 there existed no complete collection of cases from which 
 statistical information could be obtained. I accordingly 
 published a short journal article on the subject. Since 
 that period my interest in the operation has not abated, 
 and I have read with avidity whatever has come to my 
 notice on the subject ; moreover, the opportunities fur- 
 nished in the dead-rooms of the Pennsylvania Hospital 
 and of the Philadelphia School of Anatomy have enabled 
 me to study the anatomical relations of the parts con- 
 cerned. There is, so far as known to me, no volume 
 published, and very little contained in the text-books, on 
 this subject ; hence I have ventured to offer to the pro- 
 fession this monograph on Paracentesis of the Peri- 
 cardium, hoping that, as it has no rival, its deficiencies 
 may not be apparent. 
 
 J. B. R. 
 
 1118 Arch Street, November, 1879. 
 
OOTsTTENTS. 
 
 CHAPTER I. 
 
 PAOE 
 
 Causes or Pericardial Effusions 9 
 
 Varieties of Fluid Effused 12 
 
 Quantity of Fluid 14 
 
 CHAPTER II. 
 
 Symptoms of Pericardial Effusion 17 
 
 Physical Signs 20 
 
 DiAGjs'osis 29 
 
 Prognosis 34 
 
 CHAPTER III. 
 
 Treatment 36 
 
 hlstortt of the operation 88 
 
 Anatomy of the Parts Concerned 40 
 
 Cases Suitable for Operation 44 
 
 CHAPTER IV. 
 
 Methods of Operating 49 
 
 Point of Puncture 58 
 
 7 
 
CONTENTS. 
 CHAPTER V. 
 
 PAGE 
 
 71 
 
 Dangers to be Encountered 
 
 Objections to the Operation '^'^ 
 
 Treatment of Complications ^^ 
 
 CHAPTER VI. 
 
 Table of Cases 
 
 Results of the Operation 
 
 84 
 94 
 
PARACENTESIS OF THE PERICARDIUM. 
 
 CHAPTER I. 
 
 THE CAUSES OE PERICARDIAL EFFUSIONS. 
 
 In order to discuss properly any method of treating dis- 
 ease, it becomes necessary to direct attention at first to the 
 etiology, symptomatology, and diagnosis of the aftection 
 in question. It is therefore proper to devote at first some 
 time to the consideration of the conditions that give rise 
 to pericardial efl:usions. Every one has seen cases where 
 the autopsy revealed a few drachms of serum in the peri- 
 cardial sac without there having been any cardiac trouble. 
 This fluid is a transudation that has occurred just at the 
 time of death, or subsequent to that event, coming from 
 the coronary and pericardial veins, and possibly the heart 
 itself, but has not been present as a distinct ante-mortem 
 condition. This must not be confounded with pathologi- 
 cal changes, but is to be regarded as a post-mortem ap- 
 pearance, even though at times as much as three ounces* 
 of serum is found. When death has occurred from dis- 
 ease involving great venous stasis of the coronary vessels 
 the quantity of pericardial fluid found at the autopsy is 
 
 * Ziemssen's Cyclopjedia of Medicine, vi. p. 665. 
 2 
 
10 PARACENTESIS OF THE PERICARDIUM. 
 
 more apt to be great ; in which cases it becomes essential 
 that the examiner discriminate between effusions taking 
 place before and after dissolution. 
 
 The two great causes of pericardial effusions happening 
 during life are of course inflammation of the serous mem- 
 brane, and those conditions Avhich lead to a transudation 
 of the blood elements into the cellular tissue, and into the 
 various cavities of the body. The former will furnish 
 plastic matter and serum in varying proportions accord- 
 ing to the character of the inflammatory action, while the 
 latter will give rise to collections of serum or blood, either 
 separately or mingled. In the former case there will at 
 times be a certain amount of coloring matter tinging the 
 fluid, because of the rupture of some small capillary 
 vessels. In either case the effusion may become purulent 
 in character secondarily, but rarely, if ever, is the effusion 
 purulent at the beginning. Under these two heads there 
 are many causes which are operative in inducing collec- 
 tions of fluid in the pericardium. Thus the pericarditis 
 may be idiopathic, which, however, is doubted by many, 
 it may be traumatic, or it may occur as a secondary affec- 
 tion. Secondary pericarditis is frequently due to acute 
 articular rheumatism, chronic nephritis, pyaemia, scarla- 
 tina, and other exanthematous diseases. It may, also, as 
 is readily appreciated, be the result of inflammation of 
 the pleura or lungs, which structures, on account of their 
 proximity to the pericardium, may act as the starting-point 
 of the process giving rise to the pericardial effusion. In 
 " Ziemssen's Cyclopaedia of Medicine," the occurrence of 
 pneumonia and pericarditis together is dwelt upon at con- 
 siderable length. 
 
 Pericardial effusion is said to occur only in rare in- 
 stances after wounds of the sac and heart ; whether this is 
 a true statement of the case, or whether it depends upon 
 
CAUSES OF PERICARDIAL EFFUSIONS. H 
 
 the circumstance that patients with such injuries are apt 
 to die early, I am not prepared to say. 
 
 Under the second class of conditions giving rise to effu- 
 sions into the pericardial sac may be mentioned those dis- 
 eases, which cause dropsy of the other serous cavities from 
 transudation of serum, ^such as hepatic, renal, and perhaps 
 even cardiac affections. Pathological blood changes also 
 may give rise to effusion, as is seen in cases of purpura 
 and scurvy, where hemorrhage takes place and haemo-peri- 
 cardium results. Such were Kyber's cases. 
 
 The result in most instances of pericarditis is that ab- 
 sorption of the fluid occurs, and the patient suffers little 
 subsequent trouble, except there be considerable adhesion 
 of parietal and visceral layer. Hence it is that but rarely 
 does the effusion of rheumatic pericarditis increase to an 
 amount sufficient to call for operative treatment. It does 
 happen, occasionally, however, that the inflammation be- 
 comes chronic, the effusion augmented, and the sac more 
 and more distended, until death results from mechanical 
 causes. Such cases must certainly be most amenable to 
 cure by relieving the distended pericardium, and the 
 statistics of the operation of tapping show this to be the 
 fact. The inflammatory fluids furnished in idiopathic, 
 traumatic, and other cases where there is a tendency to 
 recovery, as far as the lesion is concerned, will probably 
 be absorbed in a similar manner. The effusions due to 
 profound blood alteration, and to a general dropsical or 
 anasarcous condition, must be understood as belonging to 
 a different category of causation. I should prefer to at- 
 tribute these to a process of filtration, by which the blood 
 elements escape, than to a determinate variety of inflam- 
 mation, though some may feel inclined to say there is 
 always some pericardial inflammation present even from 
 the first. 
 
12 PARACENTESIS OF THE PERICARDIUM. 
 
 Iiitra-thoracic growths may be instrumental in pro- 
 ducing effusion, either by instituting inflammatory pro- 
 cesses by reason of their contiguity to the pericardium, or 
 on account of emptying their contents into the sac, or by 
 interference with the neighboring circulation due to press- 
 ure. Under this head should be placed cases of hydatid 
 and cancerous tumors of the mediastinum, which have 
 been known to implicate the pericardium. Hydro-peri- 
 cardium has also been known to occur from mechanical 
 causes, such as pressure of an aneurism, disease of the 
 cardiac veins, their obstruction by a clot, or from sudden 
 extreme pneumothorax. 
 
 So, again, an abscess or a collection of pus in the pleural 
 cavity may find its way into the pericardium by erosion of 
 the wall of the sac. A very interesting case was seen by 
 me some years ago, where a patch of disease in the aorta 
 allowed the wall to give way, so that the blood escaped 
 somewhat slowly into the pericardium. This case proved 
 fatal of course, and was only understood after the autopsy 
 had been made, when a large amount of blood was found 
 in the pericardial cavity. 
 
 THE VARIETIES OF FLUIDS EFFUSED. 
 
 The character of the fluid contained in the pericardium 
 must vary with the cause which induces its presence. In 
 general dropsy due to hepatic or renal disease one expects 
 to find serum alone, but if the eftusion owe its origin to 
 inflammation, there will be more or less fibrin intermingled 
 with the serous fluid contained in the cavity. This is at 
 times very small in quantity, while in other instances the 
 inflammatory process is plastic in character and very little 
 serum is found, though the layers of pericardium are ren- 
 dered rough and shaggy, with an abundant deposit of in- 
 flammatory lymph upon the whole of their surfaces. "With 
 
VARIETIES OF FLUIDS EFFUSED. 13 
 
 such cases we have nothing to do in the present treatise. 
 Sometimes there may be a small quantity of blood con- 
 tained in this complex fluid, due to rupture of capillaries, 
 which have perhaps been developed in the adhesions formed 
 during the early stages or days of the pericarditis. 
 
 In certain instances of purpura and scorbutus, blood is 
 exuded here as in other situations, and the pericardial 
 cavity becomes distended with pure blood. This is not 
 very frequently observed even in these blood diseases, 
 though Bauer states* that he has seen it happen in other- 
 wise healthy people, especially in chronic pericarditis and 
 where the patients were subjects of chronic alcoholism. 
 Cancer may cause hemorrhagic pericarditis, but the con- 
 dition is very rare. Many cases of so-called hemorrhagic 
 pericarditis are only instances of blood-stained serous 
 effusion. If an adjacent abscess bursts into the pericardial 
 cavity, or a hydatid cyst is discharged in that direction, 
 the contents discovered when the sac is examined will par- 
 take of the characteristics of the fluids belonging to these 
 respective conditions. Pus may result secondarily from 
 any of these effusions, but it is not likely that purulent 
 pericarditis ever occurs as a primary condition. That ad- 
 mission of air to the interior of the sac will induce suppu- 
 ration is not to be questioned. ^ In Chairou's case, the 
 autopsy showed the existence of pus, though at the time of 
 operation the fluid withdrawn was serous. It has been 
 stated that the pus is not apt to find its way through the 
 overlying tissues to the exterior of the body, but analogy 
 would certainly lead us to expect that purulent pericarditis 
 would evacuate itself in a way similar to that occurring in 
 purulent collections in the cavity of the pleura. It is prob- 
 able that the infrequency of this pathological sequence in 
 
 * Ziemssen's Cyclopaedia, vi. p. 563. 
 
14 PARACENTESIS OF THE PEIUCARDIUM. 
 
 the former disease is due to the infrequency of purulent 
 pericarditis as an affection, and the liability of death to 
 take place in its early stages. Wyss is said* to have re- 
 corded an instance where a rib was worn away and a fis- 
 tula established which remained patulous for many years. 
 The discharge might take place into the pleural cavity, 
 bronchi, or oesophagus, if the patient survived long enough. 
 At least there seems no pathological reason to the contrary. 
 It is possible that both hemorrhagic and purulent exuda- 
 tions may become absorbed, though this result in the latter 
 case is undoubtedly to be regarded as very exceptional. 
 
 QUANTITY OF FLUID. 
 
 The amount of the pericardial fluid is a matter of major 
 importance, for it is owing to this factor that there comes 
 in certain cases a question of operation. In some in- 
 stances there is only sufiicient exudation to cause the two 
 serous layers to adhere slightly. This has been called dry 
 pericarditis, but with such cases we have nothing to do. 
 When the inflammation has existed for some time the 
 serous effusion increases with greater or less rapidity; 
 and, if the case become one of chronic pericarditis, where 
 there is no tendency of the absorbents to carry off the 
 inflammatory products, the sac may become enormously 
 distended until the lungs are pushed backwards and lat- 
 erally, and the diaphragm depressed until the abdominal 
 viscera are actually displaced. As stated above, it is usual 
 to find a small amount of serum in the pericardium as the 
 result of post-mortem changes, but in occasional instances 
 of inflammation or dropsy the quantity is really astonish- 
 ing. Corvisart mentions an instance where eight pounds 
 of serum were found. Andral givesf a case where two 
 
 * Ziemssen, vi. p. 564. 
 
 I Cliniqiie Med. , 2d ed. , 1829, vol. i., observ. iii. p. 15. Quoted by Hayden. 
 
qUANTITY OF FLUID. 15 
 
 pounds of blood were discovered in this situation. Re- 
 cently, Dr. Alonzo Clark, of ]N"ew York, has related* the 
 history- of a patient, in whose pericardium was contained 
 one gallon of sero-purulent fluid. Viry found at the au- 
 tops}' of his case (ISTo. 55) that the capacity of the sac was 
 two or three litres, and that there was on each side a sort 
 of cul-de-sac, which was on a lower plane than the central 
 part of the pericardial cavity. In cases of this kind it 
 would be difficult to get the fluid to flow from the trocar. 
 A case of purulent pericarditis is recorded,t where the 
 tension of the distended sac was so great that a puncture, 
 made at the post-mortem examination, caused the pus to 
 spurt up to the ceiling. In this patient there was an ac- 
 companying empyema. ' Dieulafoy states that the pericar- 
 dium of a well-grown adult can contain one thousand to 
 twelve hundred grammes of water, and that the sac when 
 injected overlaps the left edge of the sternum from seven 
 to twelve centimetres. The pericardium of an adult male 
 with.a normal-sized heart is capable, according to Sibson,| 
 of holding from fourteen to twenty-two ounces of water, 
 while that of a boy of six to nine years can contain about 
 six ounces. 
 
 Under the influence of the pressure exerted by the quan- 
 tities observed, as mentioned above, the pericardial sac 
 becomes greatly distended and At times thinned, though 
 the irritation is more apt to give rise to such inflammatory 
 proliferation that the walls are thickened. When the 
 effusion is great, it is usual to find at the autopsy that the 
 heart lies at the back and upper part of the sac, as would 
 be supposed from the attachments of the organ, and the 
 fact that it is heavier than the fluid. 
 
 * Phila. Med. Times, Nov. 9, 1878, p. 60. 
 
 t Lancet, 1863, vol. ii. p. 160. 
 
 X Keynolds's System of Medicine, vol. iv. p. 305. 
 
16 PARACENTESIS OF THE PERICARDIUM. 
 
 In a surgical view the discussion of the amount of effu- 
 sion deserves considerable attention, for as no one would 
 think of tapping when the fluid is small in quantity, so, 
 on the other hand, no good surgeon should hesitate to tap 
 promptly when the amount of serum or pus is great and 
 threatening the existence of the individual. It is to be 
 understood, however, that the absolute quantity would 
 not be a certain guide even if there was any method of 
 calculating it. The parts can and will accommodate them- 
 selves to a large exudation of slow formation, while a 
 rapid accumulation, though comparatively small, will in- 
 duce the most urgent symptoms. To rather large effusions 
 of serum in this situation the term hydrops pericardii or 
 hydro-pericardium has been applied, and this term, ac- 
 cording to Corvisart, is to be used respecting cases where 
 the amount exceeds six ounces. The nomenclature I 
 should prefer would differ in this respect : that, leaving 
 quantity out of consideration, I should call all effusions 
 hydro-pericardium in which the fluid is the result of un- 
 balanced circulation allowing transudation, such as occurs 
 in obstruction of the venous circulation from any cause. 
 To cases of inflammation, of subacute or chronic kind, 
 where there is fluid thrown out, the term pericarditis, with 
 some descriptive adjective, is certainly preferable, and 
 withal more scientific than hydro-pericardium. In a simi- 
 lar manner if blood were extravasated into the pericardium 
 by a simple osmosis induced by profound blood alterations, 
 the term hsemo-pericardium would be proper, whereas, if 
 the blood were furnished by rupture of vessels in a state 
 of inflammation, hemorrhagic pericarditis would be better. 
 According to this nomenclature, the appellation traumatic 
 hydro-pericardium would not be admissible, but traumatic 
 pericarditis with effusion would be legitimate. 
 
SYMPTOMS OF PERICARDIAL EFFUSION. ]7 
 
 CHAPTER 11. 
 
 THE SYMPTOMS OF PERICAKDIAL EFFUSION. 
 
 The symptoms of the condition must next claim con- 
 siderable attention, because the latent character of diseases 
 affecting the internal organs is at times sufficient to throw 
 the attendant off the track. Again, the early recognition 
 of symptoms, pointing to involvement of the pericardium 
 as a sequence of other affections, will possibly enable us 
 to institute a line of treatment to preclude the occurrence 
 of large pericardial exudation. It may be stated in ad- 
 vance that the symptoms alone of pericardial effusion are 
 not sufficiently definite to permit a diagnosis to be made 
 without the aid of physical examination. In fact, it was 
 this circumstance that deterred the earlier surgeons from 
 attempting operative measures. The case did not warrant 
 the performance of an operation until the existence of 
 fluid was determined; but the presence of fluid could 
 seldom be more than surmised until a knowledge of the 
 methods of physical exploration * was possessed by the 
 medical world. 
 
 In pericarditis there is at times of course some subjective 
 evidence of trouble before the sero-fibrinous exudation 
 occurs; but in true hydro-pericardium, as we employ the 
 term, the effusion is the first step in the history of the 
 condition. After the advent of effusion, the symptoms 
 and signs are similar without reference to etiolog}'. 
 
 The symptoms of pericarditis are, as a rule, obscured 
 by the disease which has affected the patient primarily; 
 
18 PARACENTESIS OF THE PERICARDIUM. 
 
 hence, as idiopathic pericarditis is rare, it is difficult to 
 present the incipient syniptoms to the reader in a categor- 
 ical manner. There is, frequently, a slight amount of 
 pain or uneasiness experienced, referred to the precordial 
 region, or shooting in various directions from it; there 
 may be tenderness, especially when pressure is made upon 
 the epigastrium upwards in the direction of the heart. 
 This, however, does not furnish very valuable evidence, 
 for acute gastritis, pleuritis, and hepatic trouble will pre- 
 sent a similar symptom. It has been suggested that the 
 study of the special pain due to pericarditis has been 
 perhaps too much neglected, and attempts have been 
 made to study the characters and semeiological value of 
 the pain connected with pericarditis itself, omitting that 
 dependent upon complications.* Absence of pain is said 
 by some to be more frequent in complicated than in 
 simple pericarditis, but this point is of little practical 
 value. 
 
 The slight exacerbation of fever and the occurrence of 
 rigors that would be expected as an accompaniment of 
 inflammation of this serous membrane may be absent, 
 or veiled by the febrile action belonging to the primary 
 rheumatic or nephritic disorder. There may be disturb- 
 ance of the cardiac action, as shown by palpitation and 
 increased frequency of action, which also causes rather 
 hurried respiratory eftbrts. When the sac becomes occu- 
 pied by a quantity of fluid sufficient to induce symptoms, 
 we have the same train in pericarditis with exudation, and 
 in hydro-pericardium. The heart and the adjacent organs 
 become involved by reason of the mechanical results of the 
 fluid accumulation. The pulse may be feeble, frequent, 
 and even irregular; there may be more or less urgent 
 
 * Lo Sperimentale, tomo xl. (1877) p. 419. 
 
SYMPTOMS OF PERICARDIAL EFFUSION. 
 
 19 
 
 Fig. 1. 
 
 dyspnoea or even orthopnoea; and oppression referred to the 
 cardiac region may be present. 
 
 Traube has stated that some- 
 times in copious effusion the left 
 carotid and radial arteries pulsate 
 less strongly than on the right 
 side, but he is unable to explain 
 it. The disturbed circulation 
 and respiration is due partly to 
 the fact that the fluid prevents 
 perfect dilatation of the auricles, 
 and hence the venous return 
 from the lungs is interfered with. 
 Moreover, there is pressure ex- 
 erted upon the lungs and left 
 bronchus. (Fig. 1.) Occasionally 
 there is fulness of the veins of 
 the neck, and at times venous 
 pulsation, due, probably, to the 
 pressure of the fluid upon the 
 thin-walled right auricle and the 
 intra-pericardial portion of the 
 descending vena cava. A dry cough, due to reflex irrita- 
 tion of the larynx, and vomiting are occasional accom- 
 paniments. Venous congestion of the right side of the 
 heart and the lungs, with pallor and perhaps cyanosis of 
 the peripheral parts of the body, would be expected. 
 These symptoms are due to the interference with the car- 
 diac impulse, as well as to the pressure of the enlarged sac 
 upon the veins and lungs, which have no opportunity for 
 full expansion. Singultus at times occurs, due perhaps 
 to inflammation of the phrenic nerve ; there may be dys- 
 phagia also as an accompaniment. During this time ner- 
 vous symptoms, due to imperfect cerebral circulation, are 
 
 Case of chronic pericarditis in which 
 three and one-fourth pounds of fluid 
 were contained in the sac. — Reynolds. 
 
20 PARACENTESIS OF THE PERICARDIUM. 
 
 shown, and the patient may have frequent attacks of syn- 
 cope, during which he may succumb. If he do not die 
 from sudden syncope on exertion, the end may occur from 
 oedema of the lungs; or, after presenting delirium, he may 
 sink into a comatose condition. The effusion is sometimes 
 complicated with myocarditis, which of course increases 
 the severity of the circulatory symptoms. The equivocal 
 character of these subjective symptoms serves to render 
 prominent the value of the physical signs of pericardial 
 effusion, without a knowledge of which operative meas- 
 ures would seldom have been undertaken. By these we 
 are enabled to watch the course of the affection almost 
 from the moment of hypersemia, and estimate in a some- 
 what accurate manner the amount and quality of the con- 
 tained liquid. 
 
 THE PHYSICAL SIGNS. 
 
 Let us, then, discuss the results found upon physical 
 exploration in cases of suspected pericardial effusion. In 
 the first place. What is discovered by inspection and pal- 
 pation ? If the pericardium is greatly distended there will 
 be some evidence of increased prominence of the chest 
 wall, with perhaps elevation of the nipple, and it would 
 be natural to imagine that the increase of the left side 
 would be especially marked in the pr?ecordial region. It 
 is stated that the ribs are elevated, thus presenting an 
 appearance similar to what is seen during the time of in- 
 spiration. It must be borne in mind that the bulging is 
 seldom sufficient to be a marked feature of the case, since 
 most patients will recover or the disease prove fatal before 
 sufficient fluid has collected to give rise to any great in- 
 crease in girth.* There have been instances, I believe, 
 
 * In young children with their flexible parietes this prominence of the 
 cardiac region is of more value than in the old, where rigidity, deformity 
 
PHYSICAL SIGNS. 21 
 
 where tlie bulging is said to have resembled the pointing 
 of an abscess. Should there be old adhesions of the 
 pleura, or very rigid chest walls, this sign, as mentioned 
 above, would not be of much value. Again, other affec- 
 tions of the heart itself, such as hypertroph}-, and pulmo- 
 nary affections, or mediastinal growths may present a 
 similar appearance. Fulness of the epigastrium may 
 occur in pericardial dropsy from depression of the dia- 
 phragm, and there may also be evident some congestive 
 swellins; of the liver. It has been thouo:ht that a visible 
 undulation, imagined to be due to the heart's contraction 
 and dilatation setting the serum in vibration, is an evi- 
 dence of effusion ; but this has been denied, and the un- 
 dulatory movement has, on the contrary, been attributed 
 to the actual cardiac impulse, rendered visible by trans- 
 mission to the surface, when there is no large amount of 
 effusion present. 
 
 Palpation in pericarditis furnishes little information ex- 
 cept as to the locality of the apex beat, which can perhaps 
 be determined better by auscultation, provided there is not 
 sufficient fluid to mask all sounds entirely, in which case 
 both palpation and inspection are unavailable. The char- 
 acter of the apex beat may be determined, but it is the 
 change of position to which most importance is to be 
 attached. When the sac is distended the heart can move 
 more readily, and hence, if the patient lie upon the left 
 side, the beat is felt rather more to the left than before 
 the alteration of decubitus. It should be remembered, 
 however, that a certain amount of mobility of this nature 
 occurs normally. Again, in inflammation the effusion is 
 apt to begin about the root of the organ, and consequently 
 
 from injury, emphysema, intra-thoracic tumor, and other atfections of 
 advancing life, serve to alter the physical conformation of the chest. 
 
22 PARACENTESIS OF THE PERICARDIUM. 
 
 may push the heart's base downward, and thus, making 
 it take a more horizontal position, thrust the apex beat to- 
 wards the left, whatever be the patient's position. When 
 there is sufBcient fluid to push the heart backward and 
 prevent contact with the thoracic parietes, the impulse 
 will become imperceptible. This will vary as to the time 
 of its occurrence with the strength of the heart as well as 
 with the amount of fluid; evidently, more intervening 
 fluid will be requisite to deaden a strong cardiac impulse 
 than a weak one. Provided the power of the patient's apex 
 beat be known to the observer, it is possible to gain a par- 
 tial idea of the variations occurring in the amount of fluid 
 contained in the pericardium. In cases that, from pre- 
 ceding inflammation, have the parietal and visceral layers 
 of pericardium adherent in places, there will be little or 
 no change in the locality or power of the apex beat. 
 Sometimes the impulse can be more certainly felt and 
 appreciated by allowing the subject to sit up or lean for- 
 ward, since this permits the organ to fall forward towards 
 the sternum, and impinge once more against the costal 
 cartilages and ribs. Finally, palpation at times furnishes 
 evidence of pericarditis, by reason of a friction fremitus 
 being perceptible to the surgeon as he lays his hand over 
 the prtecordium. 
 
 Of all the methods of exploration the most useful in the 
 physical examination of suspected pericardial effusion is 
 certainly percussion ; for, by the deviation from the nor- 
 mal area of dulness, and by the variations occurring from 
 day to day, a quite definite idea of the pathological changes 
 can be obtained. It is impossible to state how small a 
 quantity of serum will make its presence distinguishable 
 by increasing the cardiac dulness. Bauer says we must 
 not expect notable changes if the quantity be less than 
 one hundred cubic centimetres, though there may be 
 
PHYSICAL SIGNS. 23 
 
 many circumstances to invalidate any conclusions based 
 upon this statement. The same writer is of the opinion 
 that stress is to he laid upon the fact that the effusion in- 
 creases the area of relative cardiac dulness ; meaning by 
 relative dulness the impaired resonance found at the pe- 
 riphery of the region of absolute dulness, where the lung 
 overlies the front of the heart. It is said that there may 
 be considerable serosity in the sac without any change in 
 the area of absolute cardiac dulness, and consequently the 
 change in the region of impaired resonance is worthy of 
 being noted. This statement I believe to be correct, for 
 I have seen in the dead-room the edge of the lung overlie 
 the pericardium to such an extent that there was little or 
 none of its surface exposed. Consequently an eftusion of 
 considerable amount could be present in such a case and 
 hardly afford any region whatever of absolute dulness ; 
 and if it was found in a case of suspected effusion that 
 there was a small area of absolute dulness, it would un- 
 doubtedly be attributed to the ordinary exposed portion 
 of the heart. Hence it is of major importance to define 
 the region of relative or partial dulness, rather than to pay 
 attention exclusively to the extent of absolute impairment 
 of resonance. Rotch says that by percussion of the fifth 
 right intercostal space he was able to diagnosticate the 
 existence of seventy to eighty cubic centimetres of fluid 
 introduced into the sac experimentally.* 
 
 The various factors which produce greater intensity, as 
 well as greater extent of the relative dulness, must accord- 
 ingly be discussed. In the first place, then, the distended 
 pericardium compresses the lung in front of it against the 
 chest wall, and causes impaired resonance by preventing 
 perfect expansion during inspiration, and by furnishing 
 
 * Boston Med. and Surg. Journ., Oct. 3, 1878, p. 423. 
 
24 
 
 PARACENTESIS OF THE PERICARDIUM. 
 
 a non-resonant collection of fluid behind the thin layer 
 of pulmonary tissue. If the lung he non-adherent to the 
 adjacent tissues, it may be forced laterally and backwards, 
 and so increase the surface over which there is found a 
 percussion note of absolute dulness. On the other hand, 
 if there be old pleuritic bands, or if there exist intra- 
 pericardial adhesions, the area of dulness will be exceed- 
 ingly irregular in outline. The comparative elasticity of 
 the pulmonary tissue has also some agency in the produc- 
 tion of a large area of relative dulness, since, if the lung 
 be more or less non-compressible, it will require greater 
 intra-pericardial tension to effect its compression against 
 the anterior wall of the chest. Thus much for the me- 
 chanical occurrence of increased dulness in effusions 
 within the pericardium. 
 
 The diagnosis of the condition is rendered much easier, 
 
 as may readily be seen, when 
 the increase in dulness is sud- 
 denly developed under the ob- 
 servation of the physician, as 
 this would preclude the possi- 
 bility of the variation in per- 
 cussion being due to cardiac 
 hypertrophy, chronic indura- 
 tion of the lung, or any analo- 
 gous pathological change. It 
 has long been asserted that the 
 shape of the region of cai-diac 
 dulness in cases of effusion is 
 that of a rude, truncated tri- 
 angle, with the apex at the 
 root of the great vessels, and 
 the base downwards. (Fig. 2.) 
 Whether this is true may be discussed subsequently. One 
 
 Fig. 2. 
 
 Rheumatic pericarditis, showing re- 
 gion of dulness on percussion at period 
 of the acme. — Reynolds. 
 
PHYSICAL SIGNS. 25 
 
 of the surest sis-ns of fluid in the sac is the existence of 
 relative dulness to the left of the apex, due to the serum 
 pressing the loose fibro-serous membrane away from the 
 heart. Hayden thinks this test not available, because we 
 cannot tell where the apex is normally located.* An im- 
 portant point would be dulness below the apex beat, if that 
 fact were determinable, as it sometimes is. The fluid, if 
 considerable, would tend to depress the diaphragmatic por- 
 tion of the pericardium away from the heart, which, though 
 heavy, is suspended in the pericardial cavity by means of 
 the vessels at its base, hence the apex beat is found above 
 the lowest limit of dulness. It is usually taught in the 
 class-room that the area of dulness in pericardial eff'usion 
 is triangular, and this is given as a valuable diagnostic 
 point. If we could always have an otherwise normal peri- 
 cardium equably distended, without any intra-pericardial 
 attachments, and a pulmonary tissue with no pleural ad- 
 hesions, and with the normal conformation of outline, we 
 might occasionally see a typical pyramidal, or triangular 
 area of dulness when the patient was upright. That these 
 conditions are almost unattainable in cases of chronic dis- 
 ease, such as gives rise to large eff'usions, makes it evi- 
 dent that he, who expects to find the beautifully triangular 
 outline described in books and lectures, vdll be doomed to 
 disappointment. 
 
 After I had written the above paragraph, and in fact 
 the greater portion of this little work, and had stated else- 
 where my doubt as to the p3'ramidal area of dulness to be 
 found in pericardial effusion, I fortunately saw the article 
 of Dr. Rotch, of Boston,t containing his elaborate inves- 
 tigations of this very subject. My opinion, which was 
 
 * Diseases of Heart and Aorta, American Ed., 1. p. 388. 
 f Boston Med. and Surg. Journ., 1878, vol. xcix. pp. 389 and 421. 
 
 8 
 
26 PARACENTESIS OF THE PERICARDIUM. 
 
 founded on theoretical considerations, that the fluid would 
 collect at the bottom of the sac and not at the top, as 
 stated by many writers, is the same as that held by him 
 after careful experiments. The results obtained by this 
 gentleman are so interesting that I shall give a summary 
 of his method of experimentation, and an abstract of the 
 practical points obtained. He injected the pericardial sacs 
 of a number of subjects with melted cocoa-butter, and 
 marked out with ink the area of flatness (absolute dulness). 
 Great care was exercised to have the subject semi-recum- 
 bent, and to see that the lungs were properly inflated. 
 Subsequently the sternum was removed, and the condition 
 of the intra-thoracic organs carefully noted. 
 
 "When he injected a small amount of fluid into the sac 
 " percussion gave an increase of precordial flatness, as fol- 
 lows : beginning at the sixth rib, about two centimetres to 
 the right of the sternum, it passed upwards in a curved line 
 with the convexity outwards to the fourth right costal car- 
 tilage at its lower edge, then across the sternum to the 
 upper border of the fourth left costal cartilage, and out- 
 wards and downwards to, and to the outside of, the nipple, 
 passing down to the sixth or seventh rib." There was, he 
 says, no vertical increase of flatness, which corresponds 
 with Sibson's statements. It must be recollected that he 
 uses the term flatness to signify absolute dulness. When 
 a large amount of fluid was introduced, the area of abso- 
 lute dulness was found to be as represented in the diagram, 
 drawn directly from the cadaver (Fig. 3). 
 
 The size of the dull area varies with the amount of 
 eftusion and the compressibility of the adjacent tissues, 
 and also depends to some extent upon the position of the 
 patient. In the supine position the area will probably be 
 smaller than when the patient is sitting upright or lean- 
 ing forward, so there may be considerable deviation in the 
 
PHYSICAL SIGNS. 27 
 
 position of the region of impaired resonance as tlie invalid 
 lies upon one or other side of the body. The left border 
 is apt to be obliquely to the left and downwards ; the right 
 side of the triangle is said to be more vertical than the left, 
 and follows the border of the right lung near the right edge 
 
 Fig. 3. 
 
 Large amount of liquid introduced into sac. — Kotcli. 
 
 B, Liver. B', Portion of liver covered by right lung. D, Area of percussion flat- 
 ness caused by large effusion. S, Sternum. broken line, — Border of lung. 
 
 of the sternum. The base of the dull area is in the neigh- 
 borhood of the sixth or seventh rib. In cases of very large 
 chronic effusions, a great portion of the front of the thorax 
 may be dull on percussion. In Pepper's patient, the dull 
 area extended from a point one inch to the right of the 
 sternum to two inches to the left of the line of the left 
 nipple ; the upper limit v.'as at the second interspace, and 
 the base at the level of the seventh rib. 
 
 Percussion in cases of large pericardial effusion will 
 
28 PARACENTESIS OF THE PERICARDIUM. 
 
 generally show impaired resonance over the upper part of 
 the left lung ; the note is higher in pitch and more tympa- 
 nitic than on the right side, as in pleural eftusions, which 
 impart a semi-tympanitic note to the subclavicular re- 
 gion. 
 
 What will auscultation reveal in cases of pericardial 
 effusion ? The friction sound, due to the rubbing to- 
 gether of the inflamed surfaces of the visceral and parietal 
 layers, is pathognomonic of pericarditis, but may have 
 disappeared before the patient comes under observation, 
 on account of rapid eifusion and separation of the surfaces ; 
 or may not appear at all in cases where the effusion pos- 
 sesses more the character of a simple dropsical transudation, 
 and where very little inflammatory lymph is furnished. 
 The presence of a distinct friction sound must not lead us 
 to believe that there is but little fluid in the sac, for it has 
 been heard where two pints of fluid occupied the pericar- 
 dial cavity. It is usually, but not always, heard best near 
 the origin of the great vessels, and at times becomes more 
 audible if the body is bent forwards. The valvular sounds 
 of the heart will as a rule become more feeble or entirely 
 absent during the occurrence of great effusion, being in- 
 fluenced very much as the apex beat is modified by the 
 same pathological condition. The second sound, however, 
 is usually still heard over the base of the heart and at the 
 top of the sternum. If there be intra-pericardial adhe- 
 sions, the heart-sounds may remain quite audible at certain 
 positions, though the effusion be large. 
 
 We have thus seen that the physical signs of effusion 
 into the pericardium are much more reliable and definite 
 than any of the symptoms mentioned, and that the diag- 
 nosis must be based upon the former, since the latter are 
 not trustworthy guides to the pathological condition. 
 
DIAGNOSIS. 29 
 
 THE DIAGNOSIS. 
 
 After a consideration of the physical signs of pericar- 
 dial eflusiou, it is necessary to show how the attendant 
 may make the diagnosis between this condition and the 
 several diseases that, upon exploration, furnish somewhat 
 similar results. Ordinary cases of pleurisy are easily dis- 
 criminated by the position of the area of dulness and the 
 normal condition and position of the heart-sounds and 
 apex beat; but sacculated pleuritic effusions in the ante- 
 rior thoracic region niay give rise to much difficulty. Ac- 
 curate percussion and careful auscultation would probably 
 prove that the heart was displaced to the right in saccu- 
 lated pleural effusion of the left side. A pleural effusion 
 in the region anterior to the heart pressing this organ 
 bactward is conceivable, and as the triangular pericardial 
 dulness is not reliable, such a case would be very per- 
 plexing. Retraction of the lung, exposing more than 
 usual of the heart's surface or pneumonic consolidation 
 of the edge overlying the heart, could only be diagnos- 
 ticated by auscultatory signs, such as normal loudness 
 of heart-sounds and absence of friction in one case, and 
 bronchial respiration in the other. Mediastinal abscesses 
 and growths occurring within the thorax would be shown 
 by irregularity of dulness and displacement of the cardiac 
 sounds. In such conditions the signs would be so variable 
 that it is impossible to lay down any definite diagnostic 
 rules. The exploring-needle or trocar might give infor- 
 mation, and in my opinion would be perfectly justifiable 
 in cases where an accurate diagnosis was demanded by 
 the urgency of the phenomena. 
 
 That care in physical examination and a correct appre- 
 ciation of the signs presented by the various forms of 
 intra-thoracic disease is requisite, becomes evident when 
 
30 PARACENTESIS OF THE PERICARDIUM. 
 
 we recollect that Desault found at an autopsy that he had 
 performed thoracentesis, while the pericardium, which he 
 thought he had tapped, was adherent. Again, in B6hier's 
 case, a question has been raised whether he did not with- 
 draw the fluid from the pleura instead of the pericardium. 
 That a left-sided pleuritis might put an operator at fault is 
 readily conceivable. 
 
 At a meeting of the l^ew York Pathological Society,* 
 some specimens of pericarditis and pleurisy of the left 
 side, taken from a patient whose chest had been aspi- 
 rated twice, were shown by Dr. Loomis ; and yet it was 
 impossible, even after the autopsy, to say whether the 
 needle had really entered the pericardium or not. The 
 case operated upon by Labric and quoted in the table (jN'o. 
 34) is even more remarkable. The child was supposed to 
 have double pleurisy and pericarditis. He wished to do 
 thoracentesis, and punctured the wall in the fifth inter- 
 space about four centimetres outside of the left nipple. 
 More than a litre of purulent serum escaped. The patient 
 subsequently died, and the autopsy revealed the fact that 
 the fluid had come from the pericardium and not from the 
 pleura, which was adherent to the lung. This case of un- 
 intentional pericardial tapping shows the extent to which 
 the sac may be distended. 
 
 Hypertrophy of the heart is usually distinguishable by 
 the heavy first sound, the character of the pulse, and the 
 general symptoms. If a pericardial eff'usion increases slowly 
 and there is not much diminution in the intensity of the 
 sounds, there will be a slight resemblance to the former 
 condition. The differential diagnosis among cardiac dis- 
 eases, which it is most necessary to study thoroughly, is 
 between efl:usion and dilatation, since in each there occurs 
 
 * New York Medical Journal, 1877, vol. ii. p. 634. 
 
DIAGNOSIS. 31 
 
 extension of the area of diilness, feebleness of the sounds 
 of the heart, dyspnoea, venous congestion, and syncope. 
 To show how difficult the diagnosis may at times be, I 
 give the points which are usually mentioned as serving to 
 establish the diagnosis; yet an attentive study of them 
 makes it evident that there is no very pathognomonic sign 
 to which surgeons can fix their faith. In eifusion the per- 
 cussion dulness is stated to be triangular instead of square 
 as in dilatation ; this is certainly in many instances not the 
 fact. Again, in effusions a friction sound is often heard 
 at the base during the period of distended pericardium ; 
 but in hydro-pericardium, or non-inflammatory dropsy, 
 this must not be expected any more than in dilated heart. 
 There may be dropsy and venous stagnation, dyspnoea, and 
 cough in both affections, tliough perhaps more frequently 
 and more markedly in dilated heart. And again, the his- 
 tory is of little avail if both diseases have had a slow onset. 
 The character of the cardiac sounds is perhaps the sign 
 which often est answers a true purpose. In dilated right 
 heart the sounds are usually clear and sharp, though feeble ; 
 in pericardial effusion they are feeble and distant when 
 one auscults at the apex, but more distinct when one listens 
 at the upper part of the sternum. A sign when the right 
 auricle is dilated is pulsation of the veins of the neck, 
 though this may sometimes ocovir also in effusion. A 
 careful weighing of the points will usually enable the at- 
 tendant to establish the diagnosis ; but it is to be recol- 
 lected that a dilated right ventricle has been punctured 
 by the trocar during attempts to draw off a supposed peri- 
 cardial effusion. Fortunately, these cases seem to show 
 that no harm results from this undesirable mistake. Cases 
 of this kind have come under my notice in medical litera- 
 ture ; therefore let one weigh every symptom and sign 
 in doubtful cases before proceeding to operate. 
 
32 PARACENTESIS OF THE PERICARDIUM. 
 
 The diagnostic sign pointed out by Rotch is, if experi- 
 ence proves its accuracy, a valuable aid to the surgeon 
 about to perform paracentesis of the pericardium. He 
 says flatness at from two to three centimetres from the 
 right edge of the sternum, in the fifth intercostal space, 
 would be almost absolutely sufificient to mark the presence 
 of a small or large effusion, unless the opinions of author- 
 ities on enlarged heart are proved to be incorrect.* The 
 diagram on page 27, showing the area of flatness in effu- 
 sion, must be compared with that of enlarged heart (Fig. 4) 
 
 Fio. 4. 
 
 Enlarged heart. — Kotch. 
 
 A, Area of percussion flatness caused by enlarged heart. B, Liver. B', Portion 
 of liver covered by right lung. S, Sternum. EE'E", Line of relative dulness of 
 enlarged heart. - broken Hue, — Border of lung. 
 
 to appreciate fully this assertion. The latter represents the 
 area of flatness due to a heart increased in size by hyper- 
 trophy or dilatation, as described by standard authorities, 
 
 * Boston Med. and Surg. Journ., 1878, vol. xcix. p. 427. 
 
DIAGNOSIS. 33 
 
 and it is seen that there is little or no absolutely dull area 
 in the fifth right space. He suggests also that puncture 
 can safely be performed in the fifth right space at from 
 four and one-half to five centimetres from the edge of the 
 sternum. 
 
 The relation of some of the instances where competent 
 observers were foiled may be mentioned in this connection. 
 Trousseau came very near tapping a case where subse- 
 quent post-mortem examination showed cardiac hyper- 
 trophy with a very small amount of effusion. Roux's case 
 showed great dilatation of the heart, but no effusion what- 
 ever. Roo-er mentions the case of a child suffering with 
 dilatation and valvular disease in which he had almost 
 decided to do paracentesis, but waited. The child died, 
 and he tapped the chest after death, but then discovered 
 that there was no trace of pericarditis.* Hay den also re- 
 latesf a case where he was deceived by the physical signs 
 in a somewhat similar manner. The most remarkable 
 instance of an error of this character is that of a womanj 
 who had pleuro-pneumonia and signs of large pericardial 
 efiusion ; as she was almost moribund, a trocar was intro- 
 duced at the fourth interspace, but to the dismay of the 
 operator dark, venous blood escaped. The instrument 
 was immediately withdrawn, and the patient seemed re- 
 lieved of the distress and dyspnoea. Four weeks later she 
 died of a complication of disorders, and there was dis- 
 covered dilatation and valvular disease, but no effusion. 
 The right ventricle had been tapped, and a drachm of 
 blood withdrawn without any shock to the patient. On 
 the contrary, the abstraction of blood seemed to relieve 
 the distended and engorged heart better than phlebotomy, 
 
 * Bull, del Acad, de Med., p. 1213. 
 
 f Diseases of Heart and Aorta, American ed., i. p. 423. 
 J Transactions Clinical Society of London, viii. p. 169. 
 
34 PARACENTESIS OF THE PERICARDIUM. 
 
 as was evinced by the diminution of threatening symptoms 
 and the decreased area of duhiess. 
 
 Though these histories tend to discourage us in under- 
 taking the operation, still the results of paracentesis in 
 suitable cases are so brilliant, that we must be prepared 
 to proceed if the diagnosis can be made clear. Many 
 patients succumb because tapping has not been performed. 
 Dr. Wilks is quoted* as saying that in three cases of puru- 
 lent pericarditis, seen by him post-mortem, where tapping 
 would have been feasible, the diagnosis had not been 
 made. Let us, then, endeavor to clear up doubtful points, 
 and make an effort to unravel these knotty diagnostic 
 questions. 
 
 At times it may become desirable to determine whether 
 the effusion is the result of inflammation or due to a trans- 
 udation. The latter has the following characteristics : it 
 is usually a part of a chronic general dropsy, and is apt 
 to be an event subsequent to hydrothorax; there are 
 no severe symptoms, such as pyrexia, at the beginning ; 
 there is no friction sound, and very little disturbance of 
 the heart's action ; as a rule there is less tendency to a 
 large amount of fluid accumulation, and the area of dul- 
 ness is more apt to vary in size, and to be altered by 
 changes of posture. 
 
 I have not mentioned under the head of diagnosis such 
 affections as cerebral inflammation, gastric irritability, 
 etc., which may be confounded with early pericarditis, 
 because I am discussing the subject in its surgical aspect 
 alone, and hence have only to do with the exudation stage. 
 
 THE PROGNOSIS. 
 
 The result in cases, which show evidences of pericardial 
 effusion, nmst vary with the underlying cause of the con- 
 
 * Lancet, 1872, i. p. 893. 
 
PROGNOSIS. 35 
 
 dition, the quantity, and also the quality of the fluid con- 
 tained in the sac. Inflammatory effusions, such as occur 
 in rheumatism, if of small amount, are to he regarded as 
 favorable in respect to absorption. When the sac contains 
 many ounces of sero-fibrinous exudation, the probability is 
 that the absorbents will be unable to deal with it, and that 
 the sac will become more and more distended, and the 
 fluid in time purulent. In this event the cardiac muscle 
 is liable to become degenerated from the occurrence of 
 myocarditis, which, moreover, is at times a complication 
 of serious import from the early days of the disease. 
 
 When pus forms absorption is wellnigh impossible, and 
 the patient is likely to die from exhaustion or the results 
 produced by the purulent collection, unless surgical relief 
 is given by tapping. Occasionally, but very rarely, there 
 may be a spontaneous evacuation of the j^us through 
 the chest wall, producing a fistule. In non-inflammatory 
 transudation into the pericardium the prognosis is bad, 
 because it results from some such condition as chronic 
 nephritis, and is but a symptom of serious disease else- 
 where. The immediate danger to life in such cases, how- 
 ever, may exist in the pericardial effusion rather than in 
 the primary disease. Moreover, it must be borne in mind" 
 that renal symptoms, even the presence of casts in the 
 urine, may be secondary to circulatory disturbance, result- 
 ing from the fluid in the pericardium. Pepper's case 
 (No. 57) is an illustration of this important fact. 
 
 The hemorrhagic form of eff\ision is unfavorable, on ac- 
 count of its being due to important blood changes which 
 are inconsistent with rapid restoration of health; still, I 
 should be inclined to consider such cases more amenable 
 to medical treatment alone than those in which pus fills 
 the sac. In the latter event tapping, if the condition can 
 be recognized, should be resorted to at a comparatively 
 
36 PARACENTESIS OF THE PERICARDIUM. 
 
 early period, before surrounding structures suffer from 
 the pathologicul processes going on within the pericardial 
 membrane. 
 
 CHAPTER III. 
 
 TREATMENT. 
 
 The ordinary cases of pericarditis are undoubtedly 
 amenable to treatment by medical means, which should 
 consist of such remedies as are used in the management 
 of pleuritis. In rheumatic pericarditis of moderate se- 
 verity nothing is required but a continuance of the anti- 
 rheumatic medication. Should the inflammation of the 
 pericardium assume greater severity, it would be necessary 
 to direct our energies to its alleviation, as is also neces- 
 sary in cases of idiopathic character. When there is 
 hydro-pericardium dependent upon nephritis, or other 
 causal conditions producing dropsy, the attendant is of 
 course to look to the primary affection, and at the same 
 time get rid of the fluid in the sac by making use of ab- 
 sorbents. The activity of treatment depends upon the 
 fact that the anatomico-physiological relation of parts en- 
 hances the importance of a very few fluidounces of serum 
 in this locality. 
 
 When acute sthenic pericarditis is diagnosticated, it may 
 at times be advantageous to apply leeches or cups to the 
 prsecordium, but I have little idea that general blood- 
 letting is often required. Let it be known, however, that 
 I should not hesitate to employ it if the case seemed a 
 proper one. Those who follow the German teaching will 
 most probably resort to cold locally, as an antiphlogistic 
 and anodyne agent, and it would seem to be a rational 
 
TREA TMENT. 37 
 
 iiieasnre. I must admit, however, that my preference is 
 for warm dressings, such as poultices, since it is certainly 
 a fact that great relief is aiForded by jacket-poultices, or in- 
 deed anything furnishing heat and moisture, in pulmonary 
 inflammations ; therefore they seem indicated in cardiac 
 inflammations. Stimulants should he avoided, and small 
 doses of cardiac depressants would he advantageous in this 
 acute form, if care were observed to watch the effect. 
 
 In order to keep the inflamed organ quiet opium is of 
 value, if the patient be not suffering from chronic Bright's 
 disease, when it must be cautiously employed. Aperients, 
 diaphoretics, and the like come in as adjuvants, as in all 
 inflammations. As soon as there is evidence of cardiac 
 failure, whatever be the stage of the disease, digitalis is 
 indicated, and may be combined with alcohol in some 
 form. As salicylic acid seems to exert a favorable influ- 
 ence on rheumatism, it may have a tendency to prevent 
 the occurrence of pericarditis ; so also the alkalies and 
 bromide of ammonium may possibly have a beneficial 
 eflfect. When effusion of serum or exudation of Ij-mph 
 has occurred, our attention is directed to preventing the 
 increase, and promoting the absorption of these products. 
 Tincture of iodine, blisters, iodide of potassium, diuretics, 
 and hydragogues all come into play. At the same time 
 this action is to be assisted by tonics, stimulants, nutritious 
 diet, and digitalis ; for now the patient has begun to lose 
 strength, and the vigor of the cardiac muscle is impaired. 
 Perhaps also myocarditis may have rendered the heart 
 more feeble than the pericardial inflammation would in- 
 duce of itself. My own instincts would lead me to rely 
 upon poultices and anod^-nes, iodide of potassium, acetate 
 of potassium and juniper, digitalis and tonics, in the 
 various stages of the affection, with restriction of the 
 amount of liquid drank during the time of effusion. If 
 
38 PARACENTESIS OF THE PERICARDIUM. 
 
 liemorrhagic pericarditis was suspected, it would be well 
 to use the preparations of ergot in addition to the regimen 
 and medication adapted to the scorbutic or purpurous 
 condition. 
 
 I have said nothing regarding mercury as an antiplastic 
 agent, as its value is doubted by so many recognized 
 authorities. In the stage of exudation it could perhaps 
 be advantageously combined with the iodide of potassium 
 and the diuretic chosen. In cases of sudden asiDhyxia, re- 
 lief may be obtained perhaps by venesection, which acts 
 mechanically by reducing the amount of blood to be oxy- 
 genated and renders absorption more active. 
 
 When the line of medical therapeutics indicated has 
 been followed, and the effusion nevertheless continues to 
 augment, until symptoms of gravest import arise, and 
 there is danger of fatal consequences, or when the peri- 
 cardial fluid becomes purulent, which at all times means 
 mischief, we must throw^ aside medicinal agents and turn 
 to the domain of surgery. 
 
 Whenever dropsy of peritoneum, pleura, ovary, or knee- 
 joint bafiles our medical armamentarium, we have recourse 
 to operative measures, and decide that that which cannot 
 be absorbed must be removed by tapping. Is it possible 
 to apply this same logic to pericardial effusions ? and if 
 so, what are the results of such an operative procedure ? 
 This brings us to the consideration of paracentesis as a 
 means of relief in pericardial effusions. 
 
 HISTORY OF THE OPERATION. 
 
 Paracentesis was proposed by Riolan* as far back as 
 1649, in these words, — " Si non possis exhaurire istud per 
 hydragogen, licetne terebra sternum aperire intervallo 
 
 * Enchiridion Anatom., lib. iii. c. 4 (1649). 
 
HISTORY OF THE OPERATION. 39 
 
 pollicis a cartilagine xiphoide ?" though I can find no in- 
 stance of its heing performed until Romero, of Barcelona, 
 operated successfully, and reported his cases to the Faculty 
 of Medicine of Paris. Of the date of these operations I 
 am in douht, hut they are mentioned hy Merat in his work 
 published at Paris in 1819.* The operation was not adopted 
 because of the difficulty of making a differential diagnosis 
 between pericardial effusions and other affections, and 
 because of the supposed vulnerability of the heart. That 
 the first reason was valid is shown by the fact that some 
 of the earlier cases of so-called tapping of the pericardium 
 were not instances of this operation at all. Desault mis- 
 tookf a circumscribed pleuritic effusion for pericardial 
 dropsy, and actually operated, but the subsequent autopsy 
 revealed the fallacy. Larrey has been reported as perform- 
 ing paracentesis of the pericardium, but this also is prob- 
 ably not the fact.| Thus it is seen that the obscurity 
 involving thoracic diseases before the application of phys- 
 ical examination to the unravelling of their mysteries, was 
 doubtless the chief cause of rejecting the operation. Van 
 Swieten recognized the difficulty, but truly says, " Ten- 
 tandum esse potius anceps remedium quam nullum, dum 
 certa pernicies imminet," — A doubtful remedy must be 
 tried rather than none at all, when death is certainly 
 threatening. Hence we may re*adily perceive that the 
 doubtful remedy would have been tried had the surgeon 
 been certain that the presence of a large pericardial effu- 
 sion was the cause of the threatening symptoms. There 
 undoubtedly lingered also a feeling that the heart was too 
 vital an organ to allow the rude approach of instruments, 
 for Merat informs us that the Faculty of Medicine at Paris 
 
 * Dictionnaire des Sciences Medicales, xl. p. 372. 
 
 j- CEuvres Chirurg. recueillies par Bichat, ii. 1798 (Trousseau). 
 
 X Bulletin des Sciences Medicales, 1810 (Trousseau). 
 
40 PARACENTESIS OF THE PERICARDIUM. 
 
 did not allow the report of Romero's successful cases to 
 be printed in their Transactions, lest this most delicate 
 operation should thus be sanctioned. 
 
 ^Notwithstanding the discouraging circumstances sur-. 
 rounding the operation, writers continued to advise it in 
 suitable instances, and operators of sufficient courage began 
 to appear with greater frequency as the profession gained 
 more and more insight into the physical signs of the con- 
 dition. Karawagen employed the trocar in treating scor- 
 butic pericarditis, and was soon followed by Kyber, in 
 similar cases, who was so fortunate as to have four recov- 
 eries subsequent to the operation. The importance of the 
 subject was scarcely appreciated until thoracentesis became 
 established as the proper method of dealing with large 
 and chronic pleural etlusions ; but even then there was, 
 and up to the present time there remains, a feeling of dis- 
 trust in respect to the operation. In an article published 
 three years ago* I endeavored to place the aperation on 
 a firmer foundation, and trust that I have been able to do 
 something in that direction. 
 
 ANATOMY OF THE PAKTS CONCERNED. 
 
 Before entering upon the consideration of the operation 
 itself, it will be profitable, perhaps, to spend a little time 
 in rehearsing the anatomical relations of the pericardium. 
 The pericardium is a fibro-serous sac enclosing the heart 
 and the roots of the great vessels, or rather, surrounding 
 and being reflected upon them in such a manner that the 
 serous layer serves as a covering to them in the same 
 manner as the peritoneum does to the abdominal organs. 
 The outer portion of the serous layer is reinforced by a 
 fibrous layer. The space between the visceral layer and 
 
 * Paracentesis of the Pericardium, N. Y. Medical Journal, Dec. 1876. 
 
ANATOMY OF THE PARTS CONCERNED. 41 
 
 the outer fibro-serous layer is the cavity of the pericardium, 
 and it is here that the effusion collects in cases of inflam- 
 mation or dropsy. The sac is conical, with the apex at- 
 tached around the vessels about two inches above their 
 origin and directly behind the top of the sternum, and 
 with its base connected with the centre of the diaphragm. 
 The pericardium and heart lie in the middle mediastinum, 
 between the two pleural sacs. The costal pleura is reflected 
 upon the outside of the pericardial sac on each side as it 
 passes backward from the sternum to go to the root of the 
 lung ; from the lateral region of the pericardium it passes 
 upon the lung to become continuous with the pulmonary 
 layer, Near the middle of the sternum the two pleurse are 
 sometimes in contact for a short distance, but they diverge 
 above and below,* The pleural sacs cover the pericardium 
 in front, except a narrow strip running vertically along the 
 left edge of the sternum ; hence, unless the aspirating 
 trocar puncture at this point, the pleura must be injured 
 before the pericardium can be pierced, when the parts re- 
 tain their normal relations. f 
 
 The heart, covered by the visceral layer, lies within the 
 fibro-serous layer, behind the lower two-thirds of the ster- 
 num, and in an oblique direction, with its base directed 
 towards the right shoulder. It e^^tends about three inches 
 to the left of the median line, but only about one and a 
 half inches to the right of it. The upper border is on a 
 level with the superior edge of the third costal cartilage, 
 while its inferior surface lies upon the diaphragm with the 
 pericardium interposed. The apex of the heart is located 
 between the fifth and six cartilages, about one inch inside 
 and two inches below the left nipple. The lower border 
 
 * Braune's Topographical Anatomy, Plates XII. and XIII., English 
 edition, 1877. See also p. 106. 
 
 f See woodcuts in Braune, on pages 102-113, and Plates XII., XIII. 
 
 4 
 
42 PARACENTESIS OF THE PERICARDIUM. 
 
 of the heart, in a frozen section made by Braune,* corre- 
 sponded with the lower edge of the fifth rib, wliile the 
 pericardium extended about half an inch lower, and con- 
 tained about a tablespoonful of frozen fluid. 
 
 To determine the extent of the normal pericardium, I 
 recently made an examination of an emaciated female sub- 
 ject of moderate stature. She had died of phthisis, but 
 there was no pleural eflJ'usion to interfere with the normal 
 relations. I sawed through the sternum between the 
 second and third cartilages, and turned it carefully down- 
 wards, 80 as not to displace the pleurae or pericardium. 
 Having cut a slit in the pericardial sac, I introduced my 
 finger, and obtained its dimensions by placing the finger 
 at the right and left limit successively, and thrusting a long 
 pin through the overlying tissues until it touched the end 
 of the finger. The measurements were then taken with 
 accuracy. There was about half a fluidounce of fluid in 
 the cavity. The sac extended to the right of the median 
 line of the sternum five and a half centimetres, to the left 
 of the middle of the sternum seven centimetres. The 
 lower border of the pericardium in the middle line cor- 
 responded very nearly with the base of the xiphoid ap- 
 pendix, but at its apex the sac descended about one and 
 one-half centimetres lower. This point was nearly as low 
 as the inferior border of the sternal end of the sixth rib, 
 where it unites with the sixth cartilage. Hence a line 
 drawn from a point just above the lower edge of the end 
 of the sixth rib to the junction of the xiphoid and glad- 
 iolus would correspond with the oblique floor of the peri- 
 cardium, and give its lowest boundary. It must be re- 
 membered that the floor of the pericardium ascends as it 
 passes backward upon the curved upper surface of the dia- 
 
 * Op. cit., p. 106. 
 
ANATOMY OF THE PARTS CONCERNED. 43 
 
 phragm. This varies during-respiration. These measure- 
 ments are probably approximately correct, though the size 
 of the individual would cause differences. When the sac 
 is distended with a large eifusion the diaphragm is pushed 
 down, and the limits of the pericardium increased laterally. 
 The front of the heart and pericardium is separated from 
 the thoracic wall to a great extent by the lungs, though 
 these organs do not cover as much of the pericardium as 
 the pleurse, which extend farther forward. The right lung 
 comes to the middle of the sternum, while the left, at the 
 level of the fourth cartilage, slopes to the left, leaving the 
 ventricles uncovered by pulmonary tissue. This gives a 
 notch in the edge of the left lung, exposing the right ven- 
 tricle and the apex which is a part of the left ventricle. 
 This uncovered portion is rudely triangular, and can be 
 indicated by a circle two inches in diameter, with its centre 
 midway between the nipple and the end of the sternum.* 
 The left pleura in the subject mentioned ran straight 
 down quite near the left edge of the sternum, until, about 
 on a level with the lower end of the gladiolus, it sloped 
 off to the left; but this, as is seen, did not correspond with 
 the retraction which occurs in the border of the luno- in 
 the vicinity of the fourth and fifth interspaces. This di- 
 vergence of the pleura from the sternum occurred, I may 
 say, just about where the pericardium and diaphragm came 
 in contact, and the pleura then passed upon the diaphragm. 
 It must be understood that the measurements spoken of 
 are about the average, and that pathological conditions, 
 and possibly anatondcal variations, may cause differences in 
 the mutual relations of the organs. It is easily appreciated 
 that an hypertrophied heart will show different measure- 
 ments, and that in the event of large pericardial effusion 
 
 * Holden's Landmarks. 
 
44 PARACENTESIS OF THE PERICARDIUM. 
 
 or of pulmonary disease the lung may not intervene be- 
 tween the heart and the ribs. The pericardium may be 
 greatly distended by the fluid, and depress the diaphragm 
 to a considerable extent, and then correspond in level with 
 a lower rib than the one mentioned. As showing what 
 strange anomalies at times occur, I may mention that a 
 case has been recorded* where the pericardium was not 
 attached to the tendon of the diaphragm at all, but was a 
 bag simply resting on that muscle without any continuity 
 of fibres between them. 
 
 CASES SUITABLE FOR GPERATIOISr. 
 
 The indications for tapping the pericardium are easily 
 formulated. Whenever the effusion, whether it be serum, 
 pus, or blood, accumulates so rapidly or in such quantity 
 that it threatens to destroy life and refuses to undergo 
 absorption by ordinary treatment, it is the duty of the at- 
 tendant to tap the distended sac. It is an operation which 
 gives immediate relief by removing the cause of the urgent 
 symptoms, and the figures which I shall deduce from the 
 cases collected prove that the operation itself is not a se- 
 rious one. How long we are to trust to medical means 
 before attempting surgical interference must be left to the 
 surgeon or physician in charge of each case ; but I greatly 
 fear the tendency is to wait too long rather than to operate 
 too early. All surgeons see cases of strangulated hernia 
 lost because of valuable time having been squandered in 
 useless attempts at taxis ; so patients have died with large 
 pericardial effusions, because the fluid was not pumped 
 out with an aspirator before the hydrostatic pressure upon 
 the heart, perhaps enfeebled by disease, became intoler- 
 able, and the central organ of circulation stopped. That 
 
 * Journal of Anatomy and Physiology, 1871, vol. v. p. 114. 
 
CASES SUITABLE FOR OPERATION. 45 
 
 this picture is not overdrawn is seen by the records of 
 post-mortem examinations, where many fluidounces of 
 serum have been found in the distended pericardium. 
 Hayden, in his work on diseases of the heart and aorta, 
 says distinctly, " On two occasions at least I have had 
 reason to regret the omission of its performance."* 
 
 Some writers think the operation unsuitable for cases 
 of hydro-pericardium from Bright's disease, and contra- 
 indicated in haemo-pericardium as well as in purulent 
 effusion from acute osteo-myelitis and pyaemia, because, 
 they say, the local trouble is only a part of the disease, 
 and there is something more which the operation cannot 
 benefit. True enough ; but if it is the local effusion w^hich 
 menaces the life of the patient at the present moment, it 
 is the enemy that must be opposed. It is only palliative, 
 but palliation is not to be despised, since it gives time for 
 other measures to be adopted that may reach, at least in 
 part, the more distant and more general disease. Admit 
 "that the operation is only palliative, should one hesitate 
 to perform it because the patient may die in a few days 
 or weeks of some concomitant disorder? If paracentesis 
 was likely to cause or hasten the fatal issue, or if it aug- 
 mented the sufl'ering of the individual while doing him 
 no good, it might be allowable to hesitate ; but that such 
 is not the case is seen by intelligent observation in all parts 
 of the world. Who would decline to tap an immensely 
 distended abdomen because the patient suffered at the 
 time from incurable hepatic disease, or to draw the fluid 
 from the pleura because the patient was tuberculous ? 
 
 There are, undoubtedl}?-, conditions in which paracentesis 
 of the pericardium is followed by much more brilliant 
 results than in others. The most favorable cases are those 
 
 * American edition, vol. i. p. 421. 
 
46 PARACENTESIS OF THE PERICARDIUM. 
 
 in which a rapid pericardial efiusion has occurred as a 
 complication of rheumatism. Here there exists a disease 
 that usually has a favorable prognosis, and if the fibrino- 
 serous fluid is withdrawn from the pericardium the danger 
 of the heart complication is averted, and the patient is 
 saved from impending dissolution. 
 
 If the pericarditis is chronic, or accompanied by pulmo- 
 nary or pleural disease, there is less chance of obtaining 
 such satisfactory results, though many cases have been re- 
 ported where return to health, as far as the pericardial affec- 
 tion was concerned, has followed the performance of the 
 operation on a moribund patient. In these instances the 
 failure of perfect convalescence has usually been due to 
 the incurable character of the pulmonary lesion, or to the 
 textural changes that have taken place in and around the 
 pericardium during the continuance of the inflammatory 
 products within the sac. In certain instances this could 
 have been averted by an earlier resort to operation. When 
 the fluid is purulent it will probably be necessary to repeat 
 the tapping, but I cannot see why it would not be advisable 
 in certain cases to establish a continuous drain, as is done 
 so effectively at times in empyema. This matter, however, 
 must be discussed later, though it may be said here that a 
 second tapping does not appear to be any more dangerous 
 than the primary operation. In fact, it might be looked 
 upon as less so, since there is great probability of the 
 pleura having become adherent after the first operation. 
 
 In dropsy of the pericardium from Bright's disease, it 
 may be admitted that the fluid is at times absorbed with 
 great rapidity, and that the operation does not affect the 
 primary disease, if it be primary and not secondary to the 
 cardiac trouble ; but still I say tap, if there be evidence of 
 failing circulation and respiration, which in the best judg- 
 ment of the attendant depends on the effusion. 
 
CASES SUITABLE FOR OPERATION. 47 
 
 Dr. Pepper's case (ISTo. 57) shows this, for the kidney 
 symptoms were believed, after the lapse of time had per- 
 mitted observation, to be due to the pericarditis. Before 
 the operation the urine was slightly albuminous, and con- 
 tained tube-casts, while some weeks subsequently this 
 symptom had entirely disappeared. What a diiferent re- 
 sult would have been obtained if paracentesis had been 
 rejected in this instance, because there was a suspicion of 
 Bright's disease underlying the pericarditis ! 
 
 In hemorrhagic pericarditis the prognosis becomes very 
 unfavorable, but not hopeless, if we credit the cases of 
 Kyber, Karawagen, and others. Where there is a pysemic 
 causation the result must be still more doubtful, and yet 
 in even these instances the operation seems to me justi- 
 fiable, provided the urgent dyspnoea and depression ap- 
 pears to depend on the obstruction to the circulation. 
 
 I am inclined to go even a step farther, and suggest the 
 emploj-ment of paracentesis in those rare cases of pneumo- 
 hydro-pericarditis which occasionally present themselves 
 for treatment. A most interesting case of this kind has 
 been reported* by Dr. J. F. Meigs, in which I should have 
 been induced, I think, to.Jta»e performefd the operation of 
 tapping. The presence of air and fluid in the pericar- 
 dium was diagnosticated before death. At the autopsy 
 there were found evidences of pericarditis, with air and 
 eight to twelve fluidounces of reddish-brown liquid in the 
 sac. The air had entered by an opening leading into the 
 cesophagus, due. Dr. Meigs thinks, to " an efibrt of nature 
 to evacuate the diseased contents of the pericardium, 
 as happens in the case of empyema when the latter is 
 cured by natural processes." As the patient had had 
 double pleurisy and subsequent pericarditis, he thinks 
 
 * American Journal of Medical Sciences, January, 1875, p. 94. 
 
48 PARACENTESIS OF THE PERICARDIUM. 
 
 tliis explanation should be accepted rather than the sup- 
 position that an accidental ulceration of the a3sophagu8 
 should have occurred coincidently. If the case is inter- 
 preted in the former way, it is certainly a strong argument 
 for the adoption of paracentesis in pericardial effusions ; 
 and then it may be advanced that tapping, even after 
 pneumo-pericardium had occurred, would have given an 
 opportunity for closure of the abnormal orifice. 
 
 After it has been decided that the operation is a proper 
 mode of treating the patient under consideration, it is not 
 justifiable to delay a long time before resorting to it. In 
 very chronic cases the immediate danger of delay may be 
 less, but there is constantly going on a succession of patho- 
 logical changes, such as thickening of the membrane, ad- 
 hesion of the pericardial tissue to the structures external to 
 it, chronic pulmonary congestion, and obstruction to the 
 venous return from the head, due to the hydrostatic press- 
 ure on the right auricle and descending vena cava. On 
 the other hand, undue haste in operating on acute effusions 
 is to be deprecated, because large effusions at times disap- 
 pear Avith great rapidity under medical treatment. Still, it 
 appears that more harm is liable to result from delay than 
 from an operation done early, if due care be taken in the 
 manner of performing the operation. The danger of delay- 
 ing the removal of the fluid has not only reference to the 
 possibility of sudden asphyxia, but also to the occurrence of 
 myocarditis and fatty degeneration of the muscular wall of 
 the heart. The existence of inflammation or degeneration 
 of the cardiac muscle is more often found in purulent and 
 hemorrhagic cases than in others, but it is liable to occur 
 in all instances. Whether it be due to pressure interfering 
 with the blood supply of the organ, or to the increased work 
 thrown upon the heart, matters little, the fact remains that 
 such lesions do occur as accompaniments of pericarditis. 
 
METHODS OF OPERATING. 49 
 
 CHAPTER lY. 
 
 METHODS OF OPERATING. 
 
 "When the operation first suggested itself to observ-ers 
 and writers, the question that immediately arose was as to 
 the method of reaching the distended pericardium. The 
 earlier authorities, such as Senac, Skielderup, and Laennec, 
 proposed trephining the sternum above the xiphoid carti- 
 lage ; but this is, of course, not to be thought of at the 
 present day, for the operation would be much more serious 
 if complicated with the suppuration that must needs re- 
 sult from such a procedure. Others suggested that a pre- 
 liminary incision should be made at the point selected, and 
 the tissues divided layer by layer, as in herniotomj^, until 
 the pericardium should be reached, when a trocar was to 
 be thrust into it. Others thrust the ordinary hydrocele 
 trocar directly into the sac. 
 
 At our day aspiration is the method preferred to all 
 others. In this method there is no danger of osseous sup- 
 puration retarding convalescence by the possible burrow- 
 ing of pus among the thoracic tissues; there is no long 
 incision which might cause hemorrhage from injury to 
 the internal mammary artery or one of its branches ; the 
 entire amount of fluid can be drawn out, there is little 
 danger of the pericardial fluid dribbling into the pleural 
 sac if it should happen to be punctured, and the fine 
 needle will do little harm even if it pass through the edge 
 of the lung or strike the ventricular wall itself. 
 
 In addition to the advantao:es mentioned, the entrance 
 
50 PARACENTESIS OF THE PERICARDIUM. 
 
 of air is prevented, and thus the liability to the occurrence 
 of suppurative pericarditis subsequent to tapping is re- 
 duced to a minimum, and the wound is such a trivial one 
 that it amounts to nothing, giving little pain at tlie time 
 of operation and soon healing, so that an autopsy, even 
 if made early, shows only a small ecchymotic spot in the 
 tissues. The risk of wounding the mammary artery is re- 
 duced to a mere chance, because of the diminutive needle 
 that can be used w^hen suction power is employed. 
 
 If a trocar of ordinary kind is used, the thickened and 
 hard pericardium may be pushed in front, because of its 
 loose attachment to the thoracic parietes ; but the needle 
 of the aspirator can be thrust gradually through the tissues 
 without the same probability of displacing the sac .walls. 
 Again, the vacuum attached to the needle shows the sur- 
 geon the very moment the sac is entered, because the fluid 
 at once fills the tube and is seen flowing towards the re- 
 ceiver. This is a matter of paramount importance, since 
 otherwise the needle might be pushed onward into the 
 ventricle. 
 
 As we have stated that aspiration is to be adopted 
 in performing paracentesis pericardii, it may be asked 
 whether the ordinary sharp-pointed needle or the trocar 
 and canula, furnished with the aspirator as sold in the 
 shops, is the better instrument for perforating the peri- 
 cardial membrane. There is an objection to having the 
 pointed needle or the sharp-edged canula within the sac 
 when the fluid has been partly withdrawn, as there is a 
 possibility of the heart becoming scratched. - 
 
 There has been described* by Fitch the so-called dome- 
 shaped trocar, in which a blunt or " round-ended" fenes- 
 trated canula slides within the penetrating needle. (Fig. 5.) 
 
 * New York Medical Journal, April, 1875. 
 
METHODS OF OPERATING. 
 
 51 
 
 This, if made small and adapted to the aspirator, would 
 be an admirable instrument. In the " iN^ew York Medical 
 
 Fig. 5. 
 
 Fig. 6. 
 
 Fitch's tiocar. 
 
 Koberts's trocar. 
 
 Journal" for April, 1877, page 384, I have described an 
 aspirating trocar which is figured above. (Fig. 6.) It 
 
52 PARACENTESIS OF THE PERICARDIUM. 
 
 consists of a small, needle-pointed cylinder, within which 
 slides, on Fitch's principle, a canula attached to the air- 
 pump. The canula at the end is made flexible by a spiral, 
 and when it is thrust out beyond the end of the needle 
 curves downward ; but when it is pulled backward the end 
 becomes straight, and is entirely concealed within the 
 outer puncturing needle. The extremity of the canula is 
 pierced with a hole and there are also two other fenestras 
 just above, to give exit to the fluid. The method of using 
 it is as follows : the canula is drawn back until its flexible 
 end is hidden within the needle, and the hose from the 
 pump is attached to a small tube fixed at a right angle to 
 the posterior extremity of the canula. The outer punc- 
 turing instrument is thrust into the integument, and the 
 operator immediately causes the vacuum to exert suc- 
 tion through the internal canula; consequently a flow of 
 serum shows the moment that the instrument has entered 
 the cavity of the pericardium. The surgeon immediately 
 withdraws the needle a little, and thrusts the internal flex- 
 ible canula into the sac, so that the point of the trocar is 
 guarded, and there hangs in the sac a blunt, flexible tube, 
 against which the heart can strike with impunity. This 
 aspirating trocar is innocuous to the heart, and the curved 
 extremity allows suction to be exerted to a considerable 
 extent at the very bottom of the pericardial cavity. If 
 the canula becomes plugged with flakes of lymph, the 
 handle can be unscrewed, the inner portion withdrawn, 
 and the hose attached to the end of the penetrating needle, 
 which then acts as a large, ordinary aspirating needle. 
 
 Dr. Pepper, after operating on the case reported in 
 the table, had made a delicate double canula, the inner 
 tube of which is furnished with a fine needle-point. The 
 movements of the inner tube are regulated by a button 
 which moves along a slot in the outer tube. After intro- 
 
METHODS OF OPERATING. 53 
 
 duction the inner tube is withdrawn until its point is 
 sheathed.* 
 
 When I first described my trocar, mentioned above, I 
 was only acquainted with Fitch's trocars of large size as 
 used in ovarian dropsy, but subsequently I found that he 
 had described small capillary instruments, such as would 
 be required in paracentesis of the pericardium. These, it 
 seems to me, furnish us with the most perfect trocar for 
 the purpose. 
 
 The capillary trocars of Southey, invented for draining 
 the serum from oedematous limbs, might, if long enough, 
 be used where it was thought proper to establish a con- 
 tinuous flow of fluid from the pericardium. I merely 
 mention them to the reader because they have been used 
 for paracentesis abdominis,t but do not think the occasion 
 for their use in pericarditis is likely to arise. 
 
 In performing the operation, Potain's aspirator with a 
 vacuum jar (Fig. 7) is best, because the vessel can be emptied 
 of air before the trocar is introduced, and there is then no 
 shaking produced by pumping after the pericardium has 
 been perforated. The stop-cock should be turned so as to 
 allow the atmospheric pressure to exert its force, as soon 
 as the fenestra of the trocar is buried beneath the inte2:u- 
 ment. Thus the operator is apprised of the entrance of 
 the trocar into the fluid collecti5n. 
 
 If the fluid reaccumulates I can see no great objection 
 to repeating the operation again and again, as was done 
 in Gooch's and Bouchut's cases (Nos. 43, 48). Roger 
 looks upon repeated operations with disfavor,! but the 
 evidence deduced from the cases tabulated shows that 
 
 * The Medical News and Library, Philadelphia, March, 1878, p. 40. 
 f Monthly Abstract of Medical Science, November, 1878. 
 X Bull, de I'Academie de Medecine, 1875, p. 1283. 
 
54 
 
 PARACENTESIS OF THE PERICARDIUM. 
 
 there is no more risk in second than in first tappings, for 
 in the cases where the operation was repeated there is 
 no testimony that the procedure did harm. In many in- 
 stances the patient subsequently died, I admit, but the 
 time after operation was on an average too long to attrib- 
 ute the result to the paracentesis; and, moreover, the re- 
 
 Potain's aspirator. 
 
 accumulation was as a rule due to the fact that there was 
 some complication rendering repeated eftusions probable. 
 Aspiration is repeated in pleuritis and synovitis, and so it 
 may be in pericarditis if there is a secondary efiusion. 
 
 Some operators have injected iodine into the sac, after 
 the withdrawal of the fluid, with the idea of modifying 
 the secreting surfaces, or of inducing adhesion of the 
 layers of pericardium. Aran's successful case (^o. 19), 
 in which tapping and injection J«sag done twice, shows '^-"■h- 
 that this is not improper treatment. Kyber considered* 
 
 * Monthly Ketrospect of Medical Sciences, Edinburgh, March, 1848. 
 See also Guentlier's Blutigen Operationen, IV. iii. 
 
METHODS OF OPERATING. 55 
 
 adhesion the method of cure, because he found it had 
 occurred in tliree successful j^aracenteses where autopsies 
 were obtained long afterwards; and the fact that Pepper's 
 case showed close and universal adhesions proves the 
 probable correctness of the earlier operator's view. 
 
 Injection was adopted by Aran as he had found it 
 satisfactory in pleural effusions, and others have adopted 
 the procedure. Roger does not think it applicable,* be- 
 cause there is, he believes, danger of suppuration in the 
 sac, and of effusion of pus into the mediastinum, and be- 
 cause there is not the same tendency as in pleurisy to re- 
 traction and approximation of the two layers. ]\Iy own 
 opinion is, that since we have the aspirator, instead of the 
 old trocar, and can prevent the entrance of air, the injec- 
 tion of iodine is not indicated as it was formerly, perhaps, 
 when the admission of air was liable to change a serous 
 pericarditis into a purulent one. After simple tapping ad- 
 hesion will very probably occur, unless the effusion be due 
 to a passive dropsy, in which case adhesion is not neces- 
 sary to a cure ; hence injections are not required either in 
 inflammatory effusions, where adhesion w^ill be apt to take 
 place without any aid, nor in hydro-pericardium, where re- 
 lief of the condition depends on other factors than adhesion. 
 The simple withdrawal of the fluid, with repeated opera- 
 tions if reaccumulation take plaice, is the proper course to 
 pursue. Should the pericardial contents become purulent, 
 or if I were afraid of this contingency, then injections of 
 carbolized w^ater would be preferred to an iodized solu- 
 tion. 
 
 This brings us to the management of purulent pericar- 
 ditis, which is probably never primary, but secondary to 
 some other form of eftusion. Examination of the cases 
 
 * Op. cit., p. 1282. 
 
56 PARACENTESIS OF THE PERICARDIUM. 
 
 piiMislicd will show that the operation has at times been 
 done for existing purulent effusion, while at other times 
 the effusion was at first serous, but subsequently became 
 purulent from admission of air, or from some unknown 
 factor, probably due to the paracentesis. How are such 
 cases to be treated ? At first there is no doubt that simple 
 tapping is to be resorted to, supplemented possibly wdth 
 injection and washing out of the cavity with carbolic acid 
 solutions of the strength of one to twenty or thereabouts. 
 If the pus reaccumulate, it is almost impossible for it to 
 become absorbed, and it will increase in quantity and 
 cause pathological alterations in the pericardium and sur- 
 rounding structures. Hence I would advise a repetition 
 of the operation with carbolized injection somewhat in 
 the manner of Callender's hyperdistention of abscesses, 
 though of course this could not be practised with the 
 amount of pressure justifiable in ordinary situations. If 
 repeated tapping becomes necessary from the rapid secre- 
 tion of pus causing imminent danger, I can see no reason 
 for objecting to an opening being made to secure perma- 
 nent drainage. We know the results produced by im- 
 prisoned pus ; we know that purulent pericarditis practi- 
 cally means death unless it is removed by absorption or 
 operation, to permit of adhesion taking place. Again, we 
 see reported instances where pericardial fistulse have been 
 established by nature without deleterious results. Wyss 
 has described* a case where a rib was worn away and a 
 fistule established that remained patent until death oc- 
 curred years afterwards. Villeneuve (see Case 47) had a 
 fistulous track remain for a number of months after para- 
 centesis of the pericardium, but it finally closed. 
 
 These facts, coupled with the surgical axiom that pus 
 
 * Zienissen's Cyclopaedia of Medicine, vol. vi. p. 564. 
 
METHODS OF OPERATING. 57 
 
 should always be allowed free egress, even if the abscess 
 be in so vital an organ as the brain, influences me in my 
 opinion that purulent pericarditis demands treatment iden- 
 tical with purulent pleuritis. I have seen such excellent 
 results follow the introduction of drainage-tubes into the 
 pleural sac for the treatment of empyema, that I would 
 recommend a similar line of action in the cases under dis- 
 cussion. Let a drainage-tube be placed in the pericardial 
 sac, and let the surgeon daily wash out the cavity with 
 disinfecting solutions. This resort is to be adopted of 
 course only after tapping has been found unsuccessful. It 
 seems less dangerous than repeated tapping, because it is 
 possible that the heart may become adherent to the pa- 
 rietal layer between two successive operations, and sustain 
 injury from the puncturing instrument. 
 
 I am aware that this opinion differs from that of Roger 
 and of Pepper, and would most probably be looked upon 
 as hazardous by many. In an article written* in 1876, I 
 held this opinion, and the subsequent study of the cases of 
 Villeneuve, Juergensen, and Viry, which I had not then 
 seen, and other facts bearing on the subject, serve only to 
 confirm me in this belief. I admit that deductions from 
 pleural conditions must be received with the understand- 
 ing that there are two lungs, each of which can supple- 
 ment the other, while there is only one central organ of 
 circulation ; still the thickening of pericardium, the mac- 
 eration and disintegration of the cardiac muscle, the lia- 
 bility to spontaneous evacuation, all convince me that the 
 drainage-tube, or, if you choose, free drainage, is a better 
 alternative. Whether or not the strict antiseptic dressing 
 of Lister should be insisted upon I leave to the judgment 
 of the operator. The object to be attained is the restora- 
 
 * New York Medical Journal, December, 1876. 
 5 
 
58 PARACENTESIS OF THE PERICARDIUM. 
 
 tion of the patient to at least a fair degree of health, and 
 that universal pericardial adhesion is not incompatible 
 with this is proved by many pathological examinations. 
 
 THE POINT OF PUNCTURE. 
 
 A survey of the recorded cases of paracentesis of the 
 pericardium will show that there is a considerable diver- 
 sity of opinion as to the best point at which the puncture 
 should be made. The pericardium when distended may 
 be reached by needles thrust in at several points, as can 
 be comprehended if reference be made to the anatomical 
 description of the membrane. There are, however, com- 
 plications arising from the needle's introduction at certain 
 points and not at others, that make a careful study of this 
 question of paramount importance. 
 
 When the puncture is made high up there is great lia- 
 bility of w^ounding the auricle, because the pericardium 
 cannot be distended at its upper part as it can at the lower. 
 This accident is to be avoided, since wounds of the auricle 
 are of grave prognosis, much more so than wounds of the 
 ventricles, which indeed seem to be of little moment. 
 Again, if the aspirating instrument is introduced too low 
 down it may injure the diaphragm, or not enter the peri- 
 cardium at all. A point selected too far to the left en- 
 dangers the lung, and if located about a quarter of an 
 inch from the border of the sternum may place the integ- 
 rity of the internal mammarj^ artery in jeopardy. Thus 
 it is evident that a point is to be elected, free from com- 
 plicating sequences, which gives ready and perfect access 
 to the pericardial cavity. 
 
 Let us first consult what has been said by previous 
 writers on the subject, and endeavor afterwards to deter- 
 mine which point is to be recommended for its safety, 
 convenience, and efficiency. Larrey thought the proper 
 
POINT OF PUNCTURE. 59 
 
 position was to be found between the xiphoid cartilage and 
 the cartilages of the ribs of the left side ;* while Trous- 
 seau preferred the fifth or sixth interspace close to the 
 sternum, and said that if the cartilages were too close to 
 admit the trocar, a portion of the cartilage might be 
 trimmed away. A somewhat similar level should be 
 chosen according to the judgment of Dieulafoy, who 
 advocates the fourth or fifth interspace, but goes to the 
 distance of about six centimetres from the left edge of 
 the sternum. t He selects this position because he found 
 by experiment that the maximum transverse diameter of 
 the distended pericardium coincided with the fourth inter- 
 space or fifth rib, and that it is here that the notch in the 
 edge of the left lung is situated; hence the danger of 
 piercing the lung is reduced to a minimum. The point 
 recommended by Eoger very nearly coincides with the 
 second one of Dieulafoy. He states that the proper loca- 
 -tion for operation is in the fifth interspace, about mid- 
 way between the left nipple and the sternum, but a 
 little nearer the former than the latter landmark.^ If the 
 heart is hypertrophied, and therefore situated at the lower 
 part of the sac, or if held there by adhesions which 
 prevent its being left in its usual position when the fluid 
 accumulation pushes the pericardium and diaphragm 
 down, it may be advisable to tap in the sixth intercostal 
 space. Of this physical condition of the heart the sur- 
 geon must endeavor to become cognizant before the oper- 
 ation is instituted. Sibson's vote would likewise be in 
 favor of the fifth interspace, for he says§ the trocar should 
 penetrate above the upper edge of the sixth cartilage, 
 
 * Dieulafoy on Pneumatic Aspiration, pp. 222-224. 
 
 t Op. cit., pp. 230, 231. 
 
 X Bull, de I'Acad. de Med., p. 1279. 
 
 § Keynolds's System of Medicine, vol. iv. p. 436. 
 
QO PARACENTESIS OF THE PERICARDIUM. 
 
 more than an inch within the mammary line, and be di- 
 rected slightly downwards so as to avoid the heart, which, 
 in its healthy condition as to size, etc., has its lower border 
 above the level of the fifth space. If the heart's beat 
 is felt at a lower level than usual, he advises the in- 
 sertion of the trocar in the epigastric region, between the 
 ensiform cartilage and the seventh costal cartilage. This 
 is justifiable, because the lower border of the fully dis- 
 tended sac is usually at about the level of the lower end 
 of the xiphoid appendix ; hence, tapping may be done at 
 the middle of this part of the sternum, in the depression 
 between it and the costal cartilages. Agnew considers* 
 the sixth interspace, one inch to the left of the margin of 
 the sternum, as the most accessible route. Braune says 
 the safest position for puncture in order to avoid the pleura 
 is in the upper angle, between the left edge of the sternum 
 and the fifth cartilage, f which would be in the fifth inter- 
 space, close to the sternum. Adhesion of the pleura may 
 not occur for a long time after the presence of large effu- 
 sion ; hence he thinks it well to keep near the sternum. 
 
 If we consider the points recommended, it is evident that 
 they may be reduced in a general way to four different 
 localities, — the fourth interspace, the fifth interspace, the 
 sixth interspace, and the fossa between the xiphoid ap- 
 pendix and the cartilages of the false ribs as they ascend 
 obliquely to form the lower part of the thoracic wall. 
 After having determined which locality is best, the oper- 
 ator, if he choose either of the first three, must decide 
 whether it is preferable to keep within the line of the 
 mammary artery, or to go outward towards the nipple. 
 The objection to puncturing near the sternum is the 
 
 * Agnew's Surgery, vol. i. p. 348. 
 
 f Topographical Anatomy, English edition, p. lOG. 
 
POINT OF PUNCTURE. 
 
 61 
 
 vicinity of the mammary artery ; but, on the other hand, 
 the probability of piercing the pleura, if a point farther to 
 the left be chosen, renders the latter position to some 
 extent objectionable. 
 
 I shall discuss these points in order, and endeavor to 
 decide as to their relative merits. To make the subject 
 intelligible, I have introduced the accompanying figure 
 
 Fig. 8. 
 
 (Fig. 8), which shows the seven points mentioned by the 
 authors quoted. Each point is indicated by a cross, to 
 which is affixed the initial of the writer who recommends 
 it ; when he gives two points from which the operator is 
 to choose, the initial letter appears in two places. 
 
 An examination of the figure shows a fact that might 
 not suggest itself to one who is not in the habit of making 
 accurate thoracic explorations. It is this, that the carti- 
 lages before joining the sternum curve upwards, and that 
 
62 PARACENTESIS OF THE PERICARDIUM. 
 
 necessarily the intercostal spaces do the same ; hence a 
 puncture made in one interspace near the sternum cor- 
 responds in level with a puncture made in the interspace 
 above, two or three inches to the left of the breast-bone. 
 Again, it must be recollected that the interspaces become 
 very narrow as they approach the median line, and that 
 the fifth and sixth, and sixth and seventh cartilages are 
 frequently joined by cartilaginous bands of varying width. 
 The seven points marked are in three instances close to 
 the sternum and within the ordinary line of the internal 
 mammary artery, in three instances far to the left of the 
 artery, and in one case between these two limits. The 
 reason for selecting the vicinity of the sternum is to avoid 
 puncturing the pleura, which is reflected upon the front of 
 the pericardium, but does not extend to the left edge of 
 the sternum. 
 
 Of the three internal points, I regard that between the 
 ensiform appendix and the seventh cartilage the best, be- 
 cause the two above are located in the narrowest portions 
 of the intercostal spaces, so that it is difficult at times to 
 push a trocar or needle between the cartilages. Even 
 if the instrument would pass it would be almost impossi- 
 ble to determine the proper point of skin at which to 
 introduce it, unless the preliminary incision, suggested by 
 Trousseau, was made, but which I reject, as mentioned 
 under the methods of operating. In a dried specimen, 
 before me as I write, there is only sufficient room in these 
 situations, and for an inch or more outw^ards, to allow a 
 large pin to be passed between the cartilages. There was 
 possibly more space before desiccation, but certainly not 
 sufficient to render this an available point for paracentesis. 
 
 An aspirating needle could, doubtless, in a young sub- 
 ject, be thrust through the cartilage, but a disk of car- 
 tilage would plug the instrument and prevent the fluid 
 
POINT OF PUNCTURE. 63 
 
 flowing ; then the operator would be likely to abandon the 
 operation or thrust the needle onward into the heart itself. 
 In the case of Ponroy (Case ISTo. 33) the cartilage was 
 struck, though I do not know that he punctured in this 
 position, and a disk w^as found in the end of the needle on 
 its withdrawal ; fortunately, there was room for the escape 
 of fluid by the lateral fenestra. Moreover, the pleura 
 approaches the edge of the breast-bone so closely that it 
 would very probably be injured, and if this occur the chief 
 advantage of puncturing near the sternum is lost. It is 
 interesting, however, to know that Baizeau after his ex- 
 periments recommends the fifth space close to the sternum, 
 and believes the pleura would seldom be wounded.* There 
 is, however, plenty of space between the xiphoid appendix 
 and seventh costal cartilage, the fossa is quite easily felt 
 as a rule, and it is, moreover, lower down, and conse- 
 quently nearer the bottom of the pericardial sac and far- 
 ther from the ventricle than the other points. 
 
 If this point is selected, the trocar should be entered 
 close to the ensiform cartilage to avoid as far as possible 
 a small branch of the mammary arter}^ which traverses 
 this fossa along its internal surface. The pleura would 
 not be likely to be wounded, because it turns oW to the 
 left before it extends down as far as the xiphoid fossa. 
 There is a possibility, however, of the puncture being 
 made too low down and the needle passing directly into 
 the abdominal cavity, for the diaphragm is attached to 
 the ensiform appendix and margin of the costal cartilages, 
 and then arches upwards, keeping for a time close to the 
 sternum. Hence, if the needle be not introduced as high 
 up in the xiphoid fossa as possible, it may pass below the 
 attachment of the diaphragmatic arch, or, if entering the 
 
 * Gaz. Hebdora. de Med. et de Chir., 1868, p. 566. 
 
64 PARACENTESIS OF THE PERICARDIUM. 
 
 pericardium, may by penetratiiio; deeper project through 
 the posterior wall, and go through the arch of the dia- 
 phragm into the abdomen and wound the liver. When 
 the pericardium contains sufficient fluid to distend its 
 walls and to depress the diaphragm, and when the patient 
 is inspiring, there is of course less danger to be anticipated 
 from these anatomical relations. 
 
 A locality between the three internal and the three ex- 
 ternal points is the one suggested by Agnew ; but, though 
 I hesitate to diifer from so distinguished an anatomist and 
 surgeon, I believe it to be bad. In the first place, it ap- 
 proaches too near the cartilaginous band, which usually 
 joins the sixth and seventh cartilages, and, in the second 
 place, in an instance where I tried it experimentally, the 
 musculo-phrenic artery, one of the terminal branches of 
 the internal mammary, and a vessel of considerable size, 
 lay in dangerous proximity to the puncturing instrument. 
 The distance between the puncture and the vessel was one- 
 eighth of an inch. This may surprise the reader until it 
 is recollected that the lower part of the breast-bone tapers 
 and that the musculo-phrenic artery runs obliquely down- 
 wards and outwards; hence "one inch to the left of the 
 margin of the sternum" is not outside the vessel. I be- 
 lieve that the pericardial cavity would be reached by such 
 a puncture, but the objections mentioned serve to condemn 
 it in my mind. 
 
 Let us next discuss the three external points delineated 
 in the wood-cut. The one in the fourth interspace is too 
 high up, while that in the sixth space is probably, for most 
 cases, too low down, especially if it be carried farther to 
 the left than the junction of the sixth rib with its cartilage. 
 On these accounts I prefer that in the fifth intercostal space, 
 which is situated very near the normal apex beat of the 
 heart, close to and above the junction of the sixth rib with 
 
POINT OF PUNCTURE. 65 
 
 the coiTesponcling cartilage. It is here, as well as in the 
 fourth space, that the notch in the edge of the left lung 
 occurs, which would prevent its heing wounded even if 
 the pericardial effusion had no tendency to push the lung 
 away laterally. 
 
 The seven points given as proper for tapping the peri- 
 cardium have now been reduced to two, viz. : the fossa be- 
 tween the ensiform and the costal cartilages of the left side, 
 and the fifth interspace, near the junction of the sixth rib 
 with its cartilage. Is there anything in favor of one of 
 these over and above the other? A glance will show that 
 the two positions are practically on the same level, but the 
 diaphragm comes higher at the middle line than it does 
 laterally; hence the former point of puncture would en- 
 danger this muscle more than the latter, though if high in 
 the fossa there may not be much risk. The distended sac 
 is said to be situated a little above, and at times even a 
 little below, the point of the ensiform cartilage ; hence the 
 trocar thrust in no lower than the middle of this appendix 
 would not be likely to endanger the diaphragm. The chief 
 difference, it seems to me, resides in the fact that in one 
 instance the pleural sac is not likely to be injured, while 
 in the other case the trocar is pretty certain to perforate 
 both layers of the left pleura before it enters the ^pericardial 
 cavity, for there is not the notch^in the pleura that there 
 is in the border of the lung. In chronic pericarditis the 
 pleural cavity in front of the pericardium will frequently 
 be obliterated by inflammatory adhesions, but in hydro- 
 pericardium the pleura will be normal, and some of the 
 fluid may leak into the pleural sac during the operation 
 or after the withdrawal of the needle. This will occur 
 but rarely, and if it does, the absorbents of the healthy 
 pleura will probably cause its disappearance in a short time, 
 and with the aspirator there is no danger of pneumothorax 
 
QQ PARACENTESIS OF THE PERICARDIUM. 
 
 occurring. If it were proposed to use a drainage-tube, it 
 would be more important to be certain that the pleural 
 cavity was obliterated at the point of operation, or else 
 to select a point where the pleura was not likely to be 
 wounded. Again, if we still used the old trocar without 
 resorting to the suction power of the aspirator, this ques- 
 tion would assume more importance ; but aspiration 
 empties the sac so effectually, and the needle makes such 
 a comparatively small puncture in the pericardium, that 
 leakage is not to be expected. That leakage may occur, 
 however, is shown by Dr. Paul's case (Ro. 60). If there 
 were a coexisting pleurisy, so that the pleural sac in front 
 of the pericardium was also distended with serum, it might 
 be judicious to attempt opening the pericardium at the 
 inner situation, in order to avoid the confusion of tapping 
 two superimposed cavities containing fluid. On this sub- 
 ject the reader is referred to the subsequent discussion of 
 the complications of pericardial eifusions. 
 
 In ordinary cases, then, I believe that the probability of 
 puncturing the pleura is not a contra-indication to tapping 
 the pericardium over the normal apex beat. The possi- 
 bility, however, of wounding the diaphragm or the liver, 
 which is prone to enlargement from venous engorgement 
 in pericardial effusion, coupled with the fact that the 
 ensiform cartilage is covered at its base by the overlying 
 cartilages of the sixth and seventh ribs, making it diffi- 
 cult to determine its edge in fat subjects, renders para- 
 centesis in the fossa between the xiphoid and seventh 
 cartilage undesirable. Therefore I should tap in the 
 former locality as a rule, reserving the latter for special 
 cases where there was some indication for making an 
 exception. Rotch's suggestion to tap on the right side of 
 the sternum, in the fifth space, about four and one-half 
 or five centimetres from the edge of the sternum, must 
 
POINT OF PUNCTURE. 67 
 
 be suLjected to further clinical investigation before being 
 accepted. 
 
 The method of operating would then be as follows : 
 The patient should be as nearly recumbent as possible, in 
 order to allow the heart to fall back from the anterior part 
 of the pericardial sac. The intercostal spaces are then 
 counted by recollecting that the first rib lies under the 
 clavicle, or that the second rib joins the sternum at the 
 prominent joint between the manubrium and gladiolus, 
 and bearing in mind that the cartilages towards the median 
 line api^roach each other and ascend obliquely. If the 
 cedematous condition of the cellular tissue obscures the 
 situation, hard rubbing of the chest may render the posi- 
 tion of the ribs evident. The point is then selected in the 
 fifth space, nearer the rib below than that above in order to 
 avoid injuring the intercostal artery, and situated from two 
 to two and a quarter inches (about five to six centimetres) 
 to the left of the median line of the sternum, which, on 
 account of the irregularity of the bone, is more readily de- 
 termined than the border. It seems to me that this is far 
 enough from the median line, and is better than a point 
 nearer the nipple, because there is a possibility of making 
 the puncture beyond the limits of the pericardium. In an 
 instance where I made an experimental puncture on the ca- 
 daver in the fifth space, at a point two and one-half inches 
 from the median line, the instrument entered the pericar- 
 dial wall near its apex, and passed between the layers of 
 the membrane without entering the cavity. Although this 
 was in a case where there was no eft'usion, it shows that 
 there is such a thing as going too far to the left ; and this 
 may especially occur in instances of solidification of the 
 border of the lung complicating pericarditis, for then the 
 diagnosis of the area of dulness, due to the pericardial 
 eftusion, is difficult to establish. It would be well to vary 
 
68 PARACENTESIS OF THE PERICARDIUM. 
 
 the distance from the median line of the sternum to a slight 
 extent according to the patient's stature. In a child two 
 inches would he too far to the left; hence, the relation of 
 the median line, the apex beat, and the nipple must be 
 considered. 
 
 Care must be taken not to strike the costal cartilage lest 
 the point of the trocar be broken, or the needle plugged 
 with a disk cut from the cartilage. The caution is not in- 
 appropriate, because this has occurred, and is liable to take 
 place if the surgeon do not recollect that the cartilages have 
 a different direction from that of the corresponding ribs, 
 whose axis is dowmoards and forwards, but that of the car- 
 tilages upwards and forwards. As soon as the point of the 
 puncturing instrument is buried beneath the integument the 
 vacuum chamber of the aspirator should be attached, in 
 order that the glass index in the tubing may show by the 
 flow of fluid the instant the pericardium is opened. Unless 
 this is done, there is risk of pushing the needle into the 
 ventricular wall, and it is for this reason that an ordinary 
 trocar and canula should never be used, even if adapted to 
 the aspirating pump. If the skin is very thick, a prepara- 
 tory puncture ma}^ be made with a bistoury. It is better 
 in most instances to direct the needle backwards, but after 
 it has entered the sac its point may be turned a little down- 
 wards to avoid contact with the heart as it is thrown for- 
 ward in systole. Should the dome-shaped trocar be used, 
 or that with the flexible end described by me, there is no 
 danger on this score. I should prefer to empty the sac 
 completely if possible, as this avoids the possibility of leak- 
 ing, though some may think it better to withdraw only a 
 portion of the effiision at first, and then repeat the opera- 
 tion. As the effusion decreases and the symptoms of dysp- 
 noea ameliorate, which they generally do immediately, the 
 needle may be carefully retracted if there be fear of lacer- 
 
POINT OF PUNCTURE. 69 
 
 ating the heart's surface. Finally, it is withdrawn en- 
 tirely. The capillary puncture needs no treatment. If it 
 is thought necessary, a piece of adhesive plaster may be 
 placed over it. In cases where it is supposed that there is 
 floating lymph in the pericardium, the needle should be 
 larger than in cases of simple dropsy, when the finest 
 needle will allow withdrawal of the serum ; hence in in- 
 flammatory eifusions use an instrument of greater calibre. 
 
 I have thus discussed the method of performing paracen- 
 tesis of the pericardium ; it remains, then, to add some re- 
 capitulatory words. Be sure not to thrust the needle in too 
 deeply, for in emaciated subjects the thoracic wall is very 
 thin ; and take care not to pierce a cartilage which may lie 
 underneath the point you have considered to be in an inter- 
 space. Wlien a case shows evidence of pointing, as may 
 occur in chronic purulent pericarditis, the tapping should 
 be done at that point, without reference to its situation 
 in one or other of the localities discussed. So, also, if 
 the sounds of the heart be very loud at the point I have 
 advocated, and adhesion be inferred, the intelligent opera- 
 tor would select another point, where weakness of sounds 
 and intensity of dulness on percussion indicated that 
 the distance between the pericardium and the heart was 
 greatest. 
 
 It might happen that there was no flow of fluid after the 
 trocar was introduced through the integument, owing, per- 
 haps, to the thickened pericardium being pushed in front 
 of the instrument; or, again, the flow might cease after 
 a few moments on account of the canula being choked by 
 a plug of lymph or inspissated pus. In the former instance, 
 it is safer to withdraw the needle and to ascertain that 
 it is not stopped by a disk cut from a cartilage, inadvert- 
 ently pierced, than to persist in thrusting it deeply inward. 
 Another puncture can then be made without the risk of 
 
 3 
 
70 PARACENTESIS OF THE PERICARDIUM. 
 
 doing injury to the heart. In case of obstruction occur- 
 ring from lymph, a wire may be introduced, or better still, 
 if an aspirating trocar like that devised by me is used, the 
 inner tube can be withdrawn, and the larger outside tube 
 will probably be of sufficient calibre to allow the flakes of 
 lymph to escape. 
 
 It is understood that a needle should never be used 
 unless it is perfectly clean and not blocked up by rust. 
 A case is reported* as follows : M. Potain having a patient 
 with pericardial effusion, introduced the aspirating needle 
 in the eighth space, but no fluid escaped though the in- 
 strument had penetrated to the depth of about three 
 centimetres. The cardiac beat was felt against the instru- 
 ment, and it was withdrawn, when it was found to be 
 plugged with a piece of false membrane. No subsequent 
 trouble supervened which could be attributed to the 
 operation, but the patient died six days later. At the 
 post-mortem examination it was discovered that the peri- 
 cardium contained a litre of sero-purulent fluid. A differ- 
 ent result might have occurred if the needle had been 
 reintroduced. 
 
 In any event, great care should be exercised to prevent 
 the admission of air; if this precaution be neglected a 
 great advantage of aspiration is lost. I have frequently 
 seen the aspirator used in such a bungling manner for 
 thoracentesis, that the operator might as well have em- 
 ployed an ordinary trocar at the beginning. 
 
 * Le Progres Medical, 1876, p. 76. 
 
DANGERS TO BE ENCOUNTERED. 71 
 
 CHAPTER V. 
 
 DANGERS TO BE ENCOUNTERED. 
 
 There are but two clangers of the operation that need 
 discussion at this point, since the question of wounding 
 the pleura and diaphragm has been sufficiently considered 
 previously. It is necessary to lay before the reader the 
 possibility of hemorrhage from wounding the internal 
 mammary artery, and to mention the danger of striking 
 the ventricle and perhaps entering the cavity of the heart. 
 The point of puncture that I have recommended precludes 
 the possibility of injury to the artery, but as circumstances 
 may induce the operator to select a situation near the me- 
 dian line, the course of the artery must be mentioned. 
 After arising from the subclavian the internal mammary 
 runs downwards, parallel with the edge of the sternum, 
 crossing the inner surface of the costal cartilages, until it 
 reaches the lower edge of the sixth cartilage ; here, or in 
 this neighborhood, it bifurcates into the superior epigas- 
 tric, continuing directly downwards, and the musculo- 
 phrenic, which runs downward and outward in the sixth 
 interspace. The trunk in the region where it concerns us 
 is somewhat less than three millimetres in diameter, and 
 its two branches from say one and a half to two millime- 
 tres. The most important relation is its distance from the 
 edge of the sternum, which fortunately is increased at the 
 level of the fifth and sixth interspaces by the lessening 
 width of the bone at its lower extremity. Cruveilhier 
 and Sappey give as the average distance four to five milli- 
 
72 PARACENTESIS OF THE PERICARDIUM. 
 
 metres,* Baizeau says it is ten to fifteen millimetres, while 
 Roger found in children a distance of only two to three mil- 
 limetres. Some measurements of my own in adults show 
 it on the left side to be from one-quarter to one-half an 
 inch, which would correspond to about six to twelve milli- 
 metres, though in the neighborhood of the iifth and sixth 
 space I have seen it exceed this. Hence there is plenty of 
 room in adults to insert the trocar within the line of the 
 vessel, if it be kept close to the edge of the sternum. In 
 fat patients there may be difficulty in determining the edge 
 of the sternum with accuracy, and the artery may be acci- 
 dentally wounded. This is the chief objection to the opera- 
 tion being performed at this locality. As stated previously, 
 the point suggested by Agnew seems improper, because I 
 found that it was dangerously near the musculo-phrenic 
 branch of the mammary. If this was found in one in- 
 stance only, it renders the point more objectionable than 
 some others. 
 
 The proper method of avoiding the first danger, then, is 
 to keep away from the line of the vessel, and this is done 
 by puncturing in the fifth space about midway between 
 the sternum and the line of the nipple. If in any case 
 of operation by the aspirating needle the vessel were 
 wounded, it is probable that the surgeon would pass the 
 needle onward into the pericardium, and not be aware of 
 the . division of the artery. There would be hemorrhage 
 into the areolar tissue of the anterior mediastinum, but it 
 is to my mind doubtful whether the amount would be very 
 great. 
 
 If detected, it should be treated by cold applications to 
 the chest, with ergot and astringents internally. Since 
 the method of preliminary incision and dissection has 
 
 * Roger, op. cit., p. 1271. 
 
DANGERS TO BE ENCOUNTERED. 73 
 
 been abandoned, there is little risk of hemorrhage from 
 the mammary artery, if a proper amount of care be taken 
 in selecting the point of puncture. 
 
 An accident of much more importance is injury done 
 to the heart, which may occur from thrusting the trocar 
 into the substance, or even into the cavity of the heart. 
 A mere abrasion or scratch of the surface of the organ is 
 of little moment, for its only tendency would be to cause 
 a slight local pericarditis, which would not aggravate the 
 existing condition. It may happen, however, that the 
 operator's instrument pass into the tissue of the ventricle 
 before he is aware of it, and that he push it onward, in his 
 search for fluid, until pure blood escapes from the cardiac 
 cavity. That this is not an impossible accident is shown 
 by Roger, who believes that his case, numbered 29 in 
 the table, may have shown blood at first, because the 
 ventricle was punctured. The same question also arises 
 in considering the case of Baizeau, where clots were 
 found in the pericardial cavity at the autopsy. It must 
 be admitted, however, that no wound of the heart was 
 visible in either instance when the autopsy was made, 
 though in the latter case the patient died a couple of 
 hours after the operation. 
 
 Roger's third case is related by him as a genuine in- 
 stance of wound of the heart. I- shall, therefore, give it 
 more in detail than in the tabulated account. The boy 
 was five years old, and sufifered from pericarditis. AYhen 
 the aspirator was introduced there was at first no fluid 
 found; then there escaped blood mixed with sejosity; 
 then pure blood resembling venous blood, and this flowed 
 in a steady stream without pulsation. Two hundred 
 grammes were thus evacuated when the child became pale, 
 and the needle was withdrawn. Subsequently, it was de.- 
 termined that there was less prominence of the chest and 
 
 6 
 
74 PARACENTESIS OF THE PERICARDIUM. 
 
 less dulness, and the cardiac sounds were more superficial; 
 but the child was pale, was sweating, and had an im- 
 perceptible pulse. Improvement and cure followed, and 
 the pericardial symptoms did not return, though the case 
 was under observation for three months. The antecedent 
 organic trouble of the heart itself, however, progressed, 
 and death took place about five months after the tapping. 
 The autopsy showed dilatation of the cavities of the heart 
 with mitral insufficiency, and general pericardial adhesion. 
 Roger himself says that the blood came directly from the 
 right ventricle. 
 
 In this connection a most remarkable case, reported 
 to the Clinical Society of London,* may be mentioned. 
 It is the same case related in a preceding chapter. A 
 woman, aged twenty-seven years, had pleuro-pneumonia 
 and signs of large pericardial effusion ; as she Avas almost 
 moribund a trocar was introduced by Mr. Hulke through 
 the fourth interspace, but, to the dismay of the surgeon, 
 dark, venous blood escaped. The instrument was im- 
 mediately withdrawn, but the patient, instead of showing 
 unfavorable symptoms, seemed to be relieved of the dis- 
 tress and dyspnoea. She died four weeks later of a com- 
 plication of diseases, when the autopsy showed dilatation 
 and valvular disease of the heart, with the pericardium 
 universally adherent, but no effusion. These two in- 
 stances prove that a wound of the heart is not impossible 
 even in capable hands, and also tend to show us that 
 there is not as much danger of fatal syncope occurring 
 under these circumstances as we should suppose. In fact, 
 in the latter case, although the right ventricle was tapped 
 and one drachm of blood withdrawn, the patient ex- 
 hibited no shock or distress ; but the abstraction of blood 
 
 * Transactions Clinical Society, viii. p. 169. 
 
DANGERS TO BE ENCOUNTERED. 75 
 
 seemed to relieve the distended heart much better than 
 phlebotomy would have done, as was evinced by the 
 diminution of threatening symptoms and the decrease of 
 the area of dulness. 
 
 Though no great fatality seems to attend this accident, 
 it is one to be avoided with scrupulous care ; hence the 
 propriety of selecting a low point of puncture near the apex 
 of the heart, rather than towards the base, where the space 
 between heart and wall of thorax is less. Another ob- 
 jection to a high puncture is the much graver prognosis 
 attending wounds of the thin-walled auricle. Dr. Steiner 
 in his experiments with electro-puncture found that needles 
 could be quite safely introduced into either ventricle, pro- 
 vided they were at once withdrawn;* but it is not so safe 
 to puncture the auricles. Other observers, such as Cloquet, 
 Bouchut, Legros, and Onimus, have noticed the apparent 
 innocuousness of wounds of the heart made by capillary 
 trocars. A case bearing upon this point is recorded, in 
 which a needle had accidentally entered the chest and 
 penetrated the heart to some depth. With the exception 
 of pain no symptoms of note were observed, and the for- 
 eign body was shortly afterwards removed without causing 
 the slightest local or constitutional disturbance. Again, 
 a needle has been found firmly fixed across the ventricular 
 septum, which had evidently been there a long time, for 
 it was coated with lymph, and death had been the result 
 of other causes. f 
 
 In this connection I must mention an instance where 
 death occurred apparently from the operation of paracen- 
 tesis, though the aspirating needle did not wound the heart 
 
 * Med. Times and Gazette, May, 1873, p. 492; from Langenbeck's 
 Archiv fiir Klin. Chirurgie. 
 
 f Med. Times and Gazette, May, 1873, p. 491. 
 
76 PARACENTESIS OF THE PERICARDIUM. 
 
 itself, and failed to reach the effusion. A man was sup- 
 posed to have effusion in the pericardium, and aspiration 
 was attempted in the third interspace, but no fluid escaped, 
 and he died almost immediately. The autopsy revealed 
 the fact that the instrument had pierced not the heart wall 
 as might be expected, but had penetrated the thickened 
 pericardium at a point where it was adherent to the heart. 
 The pericardium was adherent to almost the whole of the 
 left heart, while at the right there was a cavity containing 
 twelve hundred grammes of fluid. There was also valvular 
 disease.* How to explain this sudden death from shock 
 I do not know. The operation was done higher up than 
 usual, and death may have been due to some interference 
 with cardiac action resulting from injury to the auricle 
 with its adhering pericardium, that had assumed the func- 
 tions of the auricular wall. It is possible that the man, 
 enfeebled by valvular disease and the pressure from the 
 large effusion, was unable to withstand the mental and 
 physical shock produced by the operation. I have omitted 
 this case from the table of cases of paracentesis pericardii 
 because the pericardial cavity was not opened, and there- 
 fore it could not be classed among them. The importance 
 of the case requires its insertion here in order that I may 
 present a scientific and non-partisan view of the subject 
 in all its bearings. 
 
 The experiments of Steiner and others have been quoted, 
 not to encourage careless employment of surgical means 
 in treating pericardial eftusions, but to let it be known that 
 we should throw aside the foolish prejudice that makes us 
 shun operative interference in pericarditis because of the 
 supposed vulnerability of the heart. If the cases of peri- 
 
 * Bull. Gen. de Therap., 1878, tome xciv. p. 428; from Union Med. 
 and Gaz. des Hop., 1878, p. 310. 
 
OBJECTIONS TO THE OPERATION. 77 
 
 cardial effusion be properly selected, and diligent care be 
 exercised in the performance of the operation, the risk of 
 striking the heart is very slight. If the heart should be 
 punctured through some unforeseen contingency, such as 
 an unsuspected adhesion, it will probably, if we are to 
 judge by the cases quoted, add little to the gravity of the 
 case, which, to say the least, is already very grave when 
 the operation is suggested. Hence I conclude that the 
 fear of wounding the central organ of circulation should 
 not deter the surgeon from tapping the pericardium, if the 
 diagnostic signs warrant the attempt. He must be careful 
 that no disk of cartilage or shred of membrane occludes 
 his needle, and then he can push it onward until the index 
 shows the fluid escaping. In thick, oedematous, or fatty 
 walls it may be necessary to go to a depth of four or five 
 centimetres before reaching the fluid; hence it is abso- 
 lutely essential that the needle's patulency be assured. 
 
 OBJECTIONS TO THE OPERATION. 
 
 I deem it proper to devote some time to considering the 
 objections that have been advanced against the adoption of 
 paracentesis pericardii as a justifiable procedure. In the 
 first place, it has been said almost with a sneer that the 
 operation is merely palliative. Kow, even if I were 
 willing to admit this, which ^ am not, I should still 
 insist upon the performance of paracentesis of the pericar- 
 dium in proper cases. In many incurable afi'ections we 
 must labor with all our might to palliate the sufferings of 
 the patient. If it were right to do so, the surgeon's feel- 
 ings of humanity might prompt him to hasten dissolution 
 when he sees and hears the agony of a man with hydro- 
 phobia; but no, he must palliate. He can destroy a brute 
 to relieve prolonged suffering, but he must sustain the 
 life of a human being. Hence palliative measures are 
 
78 PARACENTESIS OF THE PERICARDIUM. 
 
 urgently demanded in every department of medicine. If 
 a few days can be added to a life by tapping the pericar- 
 dium, it should be done; aye, and done quickly. Allbutt, 
 when discussing the objection of one who says, "In the 
 majority of cases I believe the result has been unfavor- 
 able,"* argues, very properly, that "unfavorable" must 
 mean that the operation itself caused death, hastened the 
 fatal issue, or augmented the suifering of the patient while 
 doing no good whatsoever.f An examination of the ac- 
 companying table shows that these effects are not charge- 
 able to the operation, but that it, as a rule, relieves suffer- 
 ing at once and prolongs life. 
 
 This feeling of hostility to the operation has of late years 
 been considerably modified, and I doubt whether Billroth 
 would now say that the operation seemed almost like pros- 
 titution of surgical skill, or speak of its resemblance to a 
 surgical frivolity. | 
 
 Jaccoud speaks of the operation as legitimate at times, 
 but says that, after the performance of paracentesis of the 
 pericardium, the liquid is reproduced with great facility 
 on account of the diminution of extra-vascular pressure. § 
 This statement I am unwilling to accept as a clinical fact, 
 and, even if true, I should not feel that it carried much 
 weight as an objection to the operation. 
 
 As an answer to those who disparage the operation be- 
 cause of its merely palliative character in many instances, 
 I will state that in the table of 60 cases of operation there 
 are recorded 36 deaths. Of these fatal cases, 23 patients 
 are known to have survived the operation for one da}^ or 
 
 * British Medical .Journal, July 2, 1870. 
 t Ibid., July 9, 1870, p. 32. 
 
 X Handbuch der Allgemein. und Speciellen Chirurgie, III. Bd., II. 
 Abt., I. Lf., 163 S. 
 
 I Pathologie Interne, i. 646. 
 
OBJECTIONS TO THE OPERATION. 79 
 
 more, 9 are known to have lived less than a clay after the 
 operation, and in 4 instances the time of survival is not 
 given. The average time of survival of those who are 
 known to have lived one day or more is over 27 days. 
 The greatest length of time was 160 days. If it be recol- 
 lected that most cases are not considered proper for opera- 
 tion until the patient is almost moribund, this is certainly 
 a good showing. Four weeks is a long time to add to a 
 man's life, especially when it can be done by an operation 
 that causes so little pain. 
 
 The probability of adhesion of the two layers of the 
 pericardium occurring after tapping has been held as a 
 contra-indication, because adhesions may induce, it is said, 
 valvular disease or pathological changes in the cavities of 
 the heart. If such is the ultimate etfect of adhesion, it is 
 better than the existing condition of pericardial effusion, 
 which gives rise to m^^ocarditis and pathological sequences 
 of more immediate danger. That general adhesion does 
 take place in inflammatory effusions is probable. Kyber 
 found that it had occurred in three of his cases of recovery 
 after paracentesis, where autopsies were obtained long 
 afterwards;* and Pepper's case (No. 57) showed the same 
 condition when the post-mortem examination was made 
 fifteen months after the operation. It would seem that a 
 radical cure is to be looked for i^i the occurrence of union 
 of the two surfaces, and if this be true, the objection to the 
 operation on the score of pericardial adhesion falls. After 
 all, the degree of agency exercised by adhesions in the 
 production of other cardiac lesions is a disputed matter, 
 as will be seen by careful perusal of the works on heart 
 affections. Are we to reject an operation which prevents 
 imminent death because we fear it will lead to a condition 
 
 * Monthly Ketrospect of Medical Science, Edinburgh, March, 1848. 
 
80 PARACENTESIS OF THE PERICARDIUM. 
 
 tliat lias a doubtful agency in producing otlier less fatal 
 ailments ? 
 
 An objection of more force than either of those thus far 
 reviewed is the assertion that the fluid accumulates with 
 greater rapidity after tapping than previously, and that it 
 has a tendency to become purulent. We have not sufli- 
 cient data to answer this point, but I do not see that the 
 objection is of any more value than against aspiration in 
 pleuritis, where, if the fluid reaccumulate, the needle is 
 introduced again and again, and cure finally effected ; and 
 if the pleural efirision become purulent, it is evacuated 
 either by repeated tapping or by continuous drainage. 
 The proper method of obviating suppuration is to avoid 
 the entrance of air into the cavity during the operation. 
 The line of treatment which meets this indication, and 
 the course to pursue after pus has formed, will be found 
 in the chapter which treats of the methods of operating. 
 In Frerich's ward, where thoracentesis is frequently per- 
 formed, no serous efiusion, it is stated, becomes purulent 
 if the instrument be disinfected and the air excluded from 
 the pleural cavity.* This would probably correspond with 
 general experience. Is there any difierence in this regard 
 between pleura and pericardium ? 
 
 There can be no valid objection urged against a second 
 operation if the first has been deemed justifiable. A 
 study of the table of operations will furnish information 
 concerning this matter. The cases of Scliuh and one or 
 two others must be omitted, since in them the first tapping 
 failed to give exit to the fluid, and a second operation was 
 immediately performed. 
 
 It is stated that the operation was done more than once, 
 as follows : 
 
 * Medical and Surgical Eeporter, September 30, 1876, p. 274. 
 
OBJECTIONS TO THE OPERATION. 81 
 
 There were tapped twice . . . . . .11 patients. 
 
 " was " three times .... 1 patient. 
 
 " " " six times 1 " 
 
 " " " eight times .... 1 " 
 
 There was a repetition of the operation therefore in 14 patients. 
 
 The patient wlio was tapped six times (I^o. 43) lived 
 thirty-eight days after the first operation, or ten days after 
 the sixtli, and finally died, having peritonitis in addition 
 to pericarditis, Bouchut's patient (IS'o. 48) was tapped 
 eight times, and lived thirty-four days after the primary 
 operation. Death occurred three days after the final tap- 
 ping, when the heart itself was punctured. The shortest 
 interval between the original operation and the second 
 was rather less than one day ; in other cases the period is 
 shown by the full histories to have been as long as fourteen, 
 fifteen, and seventeen days. 
 
 Let us return, however, to the questions : Does paracen- 
 tesis itself cause rapid reaccumulation ? and, if so. Is the 
 second operation more dangerous than the first ? In the 
 first place, there are twenty-three cases reported ^where 
 recovery followed paracentesis without a second operation 
 being necessitated, and in the fourteen instances where it 
 was required there was additional disease in every case. 
 Secondly, of the fourteen cases of repeated tapping thir- 
 teen died ; but in all of them there was either disease of 
 the heart or lungs, as in nine, scurvy or abdominal disease, 
 as in three, or brain disease, as in one ; and, indeed, the one 
 patient who recovered after double tapping had phthisis 
 (Eo. 19). These statistics seem to show pretty conclu- 
 sively that repeated tapping is not demanded as a sequel 
 of first paracenteses, but is required because the patient's 
 condition causes a spontaneous reaccumulation, which 
 would occur if the efiiision was suddenly removed by any 
 other method that did not at the same time improve his 
 
82 PARACENTESIS OF THE PERICARDIUM. 
 
 diathesis. They also militate against tlie idea that there 
 is decided risk in tapping more than once, for, though it 
 is not proved that these patients died of the accompanying 
 disease, yet it is shown that the fatal cases, where repeated 
 paracentesis was performed, were decidedly unfavorahle. 
 Therefore the evidence is of value, though it be negative. 
 More positive evidence is the fact that, in nine of the thirteen 
 fatal cases of repeated tapping, the time of survival after the 
 second operation was one day or more, while in some cases 
 the patient survived many days after the second operation. 
 In the four remaining instances death occurred in less than 
 a day, or the time is unknown. There is no proof in this 
 that a second operation is to be dreaded any more than the 
 primary one, except in so far as it suggests the probability 
 of some affection complicating the pericardial effusion. 
 
 TREATMENT OF COMPLICATIONS. 
 
 Having carefully taken up in detail the steps to be pur- 
 sued in treating pericardial effusions, I shall occupy a few 
 pages with some consideration of the management of com- 
 plications that may exist as causes or results of the effusion 
 in the pericardial cavity. Pleuritis with effusion is a 
 not uncommon accompaniment of pericarditis, as has been 
 shown when discussing the aetiology of inflammation of 
 the heart's investment ; so, also, pneumonia is frequently 
 found in a similar relationship. These affections must be 
 treated on the general principles that guide the physician 
 in managing cases unaccompanied by pericardial disease. 
 The difficulty of diagnosis that may arise between left 
 pleuritic effusion, especially if encysted, and effusion in 
 the pericardium has been mentioned. Occasionally it is 
 hard to calculate the degree of causation exerted by these 
 two effusions in producing the symptomatic manifesta- 
 tions observed. There exist certain symptoms, such as 
 
TREATMENT OF COMPLICATIONS. 83 
 
 cyanosis, dyspnoea, feeble circulation, etc.; are they due 
 to the serum in the pleura or to that in the pericardium ? 
 Wlien the pleural eiFusion is relatively much greater in 
 amount, the question can be decided ; but cases arise in 
 which it is almost impossible to say which is the more 
 active agent. If there be any doubt, it is proper to per- 
 form thoracentesis first, and then await results ; if relief 
 does not follow, the pericardium is to be punctured sub- 
 sequently. There is no objection to doing both opera- 
 tions at one time, if they are indicated by the condition 
 of the patient. 
 
 The treatment of renal symptoms must be governed by 
 the general indications in much the same manner ; but I 
 wish to enforce attention to the fact that albuminuria and 
 urfiemic convulsions may be due to the pressure from the 
 pericardial eifusion, and that the surgeon should not hesi- 
 tate to tap because he finds evidences of kidney trouble. 
 Often there is hydro-pericardium as a part of a general 
 dropsical condition, induced by renal disease, but the re- 
 verse may be the proper relationship. In other words, 
 what is cause in one instance may be effect in another. 
 The nephritic congestion or inflammation is to be treated 
 by diuretics, such as digitalis, scoparius, juniper, and by 
 derivatives, such as jaborandi; but it is useless to mention 
 measures or methods of medication, since this belongs to 
 general clinicar medicine, and not to the subject of our 
 present volume. 
 
 There have been a few cases recorded where a pericar- 
 dial fistula has been established either by a spontaneous 
 or operative evacuation of the eftusion. Some cases so 
 called have doubtless been pleural fistules, or superficial 
 sinuses due to a subtegumentary abscess. If they are 
 truly pericardial, I advise dilatation of the orifice with 
 compressed sponge, and washing of the pericardial cavity 
 
84 PARACENTESIS OF THE PERICARDIUM. 
 
 with astringent and disinfectant solutions. It may be that 
 the layers of pericardium are adherent, and that the sinus 
 opens into a small suppurating pocket between the visceral 
 and parietal membrane ; or this pocket may be external to 
 the pericardium entirely, and be formed in the midst of 
 some new tissue occupying the mediastinum. It is, of 
 course, useless to expect closure of the external opening 
 if there is a continual secretion of pus within, and it 
 may be necessary to lay open such cavities. Sinuses 
 that are superficial demand similar treatment. They 
 should be laid open with the bistoury, and forced to gran- 
 ulate from the bottom. It is possible that such patho- 
 logical conditions may depend for their existence upon a 
 diseased rib or cartilage; if such be the fact, resection, or 
 removal of the diseased tissue with the burr or chisel, is 
 to be considered. 
 
 CHAPTER VI. 
 
 TABLE OF CASES. 
 
 After an extended search through very many volumes 
 of text-books, monographs, and journals, and after a good 
 deal of correspondence, I have collected sixty cases of para- 
 centesis of the pericardium, and have embodied them in 
 the followino; table. Some cases that I have found men- 
 tioned, or have heard of, I have rejected, because I could 
 not get any definite information of them, or because I be- 
 lieved them to be of doubtful authenticity. I have person- 
 ally examined many files of German, French, Italian, and 
 Spanish journals in order to get trace of the cases operated 
 
TABLE OF CASES. 85 
 
 upon tliroughout the continent of Europe; and the fact 
 that I have again and again met references to cases al- 
 ready tabulated, seems to me conclusive evidence that my 
 search was pursued with a considerable degree of thor- 
 oughness, and that I have missed very few recorded oper- 
 ations. It may be, and probably is, a fact, that I have 
 failed to collect all ; but a prolonged study of indexes and 
 a watchful eye on current literature during a number of 
 years have probably given me an opportunity of finding 
 nearly all the published operations. It may be observed 
 that some of the cases, that appeared in a table published 
 by me a few years ago, are changed in certain respects 
 in the present work. This is due to my having gained 
 more reliable information respecting the points of inter- 
 est. In this table I have omitted Bowditch's case, which 
 was placed in the otlier on the authority of Trousseau. 
 Dr. Pepper states that Bowditch says he never performed 
 the operation. "When compiling the first series of cases I 
 wrote to Dr. Bowditch, of Boston, but never obtained any 
 answer from him, owing doubtless to my letter being mis- 
 laid, for I know that he was away at the time. 
 
 Some of the cases have two names attached. This is 
 due to the fact that occasionally a case is reported in 
 different journals under a difi'erent name, owing to the 
 journal which makes the abstract or excerpt getting the 
 names of the operator and attending physician confused. 
 In this way I have several times met the same case under 
 a different heading, and have thought I had found a new 
 instance of the operation, until comparison of the dates, 
 ages, results, etc., has proved that I was in error. To 
 avoid misapprehension I have added the second name in 
 parenthesis. 
 
86 
 
 PARACENTESIS OF THE PERICARDIUM. 
 
 H 
 
 r. 
 
 a 
 « 
 Id 
 
 Eh 
 
 a 
 P5 
 
 Diet, des Sciences Me- 
 dicales, Paris, 1819, 
 xl. 371. 
 
 Do. 
 
 Do. 
 
 GUnther, Blutigen 
 
 Operationen, iv. 3, 
 
 British and Foreign 
 Medical Review, 
 July, 1841. 
 Do. 
 
 -a a 
 
 Monthly Retrospect 
 of Medical Sciences, 
 Edinburgh, March, 
 1848, i. 35. 
 
 Archives Gene rales de 
 Medecine, Novem- 
 ber, 1854. 
 
 GUnther, Blutigen 
 Operationen, iv. 3, 
 102. 
 
 Do., and also Monthly 
 Retrospect of Medi- 
 cal Sciences, March, 
 1848, i. p. 35. 
 Do. 
 Do. 
 
 i 
 
 .1 
 
 1 
 
 
 Scurvj'. 
 Scurvy. 
 
 a 
 
 Scurvy. 
 
 Phthisis. 
 Scurvy? 
 Scurvy. 
 
 Scurvy. 
 
 H 
 
 o 
 u 
 o 
 
 1 
 w 
 
 Hemorrhagic scorbutic pericar- 
 ditis. Drew off Oiijss. Quite 
 well five months later. 
 
 Scorbutic pericarditis. 
 
 Tapped first in third inter- 
 space. Case was one of en- 
 cephaloid disease of thoracic 
 
 viscera. 
 Scorbutic pericarditis. 
 
 Tapped twice. 1500 grammes 
 and 400 grammes. Drainage- 
 tube left in six hours. 
 
 Hemorrhagic effusion. Re- 
 moved 5 lbs. Recovered in 
 six weeks. 
 
 Scorbutic pericarditis. Was 
 living one and a half years 
 later. 
 
 Scorbutic pericarditis. 
 
 Tapped twice, with interval of 
 17 days. Scorbutic pericar- 
 ditis. 
 
 
 2'3 
 
 3" 
 
 ■a 
 
 3 ~S 
 
 69 days. 
 17 days. 
 
 •q;^3a 
 
 iHcw 
 
 iH 
 
 - 
 
 r- tH 
 
 •iCjSAoos]! 
 
 IH IH 
 
 lH 
 
 
 r-( r-l iH rH 
 
 
 Bistoury and scis- 
 sors. 5th inter- 
 space. 
 
 Do. 
 
 Do. 
 
 Not stated. 
 
 Trocar. 5th inter- 
 space. 
 
 Do.? 
 
 p 
 E-i 
 
 Trocar.* 4th inter- 
 space. 
 
 Trocar. 5th inter- 
 space. 
 
 Trocar. 
 
 Trocar. 4th inter- 
 space. 
 
 Do. 
 Do. 
 
 •aSy pnu X9g 
 
 M. 35 
 
 M. 37 
 M. 45 
 P. 14 
 
 g s 
 
 1^ 
 
 oa 
 
 8 a g a g'a 
 
 1 
 Q 
 
 Before 
 1819 
 
 Do. 
 Do. 
 
 1827 
 
 o en 
 
 1 
 
 O rH (M CO lOUi 
 
 X » « s »« 
 
 O 
 
 1, Romero. 
 
 2, Romero. 
 
 3, Romero. 
 
 4, Jowett. 
 
 5, Karawagen. 
 G, Karawagen. 
 
 -a 
 a 
 
 m 
 
 8, Kyber. 
 
 9, Heger. 
 
 10, Schonberg. 
 
 11, Kyber. 
 
 12, Kyber. 
 
 13, Kyber. 
 
TABLE OF CASES. 
 
 87 
 
 H 
 
 a 
 
 H 
 
 GUnther, and also 
 Monthly Retrospect 
 of Medical Sciences, 
 March, 1848, i. p. 35. 
 
 H. II. Smith's Sur- 
 gery, ii. 358. 
 
 Bull, de TAcad^mie 
 de Medecine, 1875, 
 p. 12CG. 
 
 Trousseau, Clinical 
 Medicine, iii. 370. 
 
 Archives Gfinerales de 
 Medecine, Novem- 
 ber, 1854. 
 Trousseau, Clinical 
 Medicine, iii. 380. 
 
 Id., iii. 391. 
 Id., iii. 391. 
 Id., iii. 383. 
 Ilalf-Yeaily Abstract 
 of the Medical Sci- 
 ences, XXV. p. 95. 
 
 Trousseau, Clinical 
 Medicine, iii. 304. 
 
 GUnther, Blutigen 
 Operationen, iv. 3, 
 102. 
 
 ■3. 
 
 a 
 
 
 Scurvy. 
 
 Phthisis. 
 
 Died of 
 pneu- 
 monia. 
 
 Phthisis. 
 
 Valvular 
 disease. 
 
 Pleurisy 
 
 ami 
 
 phthisis. 
 Scurvy 1 
 
 OS 
 
 •< 
 s 
 
 Scorbutic pericarditis. 
 
 Removed f. oz. v. Left hospital 
 in a few weeks. 
 
 C15 grammes. 18 months after 
 was woiking as a sailor. 
 Roger says this was a com- 
 plete cure. 
 
 Removed 400 grammes. 
 Tapped jdeura ahso for ef- 
 fusion. Under notice three 
 months. 
 
 Removed 250 gi-ammes. 
 Tapped previously in 7th in- 
 terspace ; no fluid obtained. 
 
 Tapped twice. F. oz. xxviij 
 and f. oz. xlix. Injected 
 iodine and iodide of potas- 
 sium after each tapping. 
 
 Tapped twice. First, 500 
 grammes ; second, three days 
 later, 400 grammes. Tapped 
 abdomen for ascites. 
 
 Removed f. oz. iij ? Tapped 
 pleura accidentally at same 
 time. 
 
 Hemorrhagic pericarditis. 
 
 
 • 
 26 days. 
 
 21 days. 
 
 5 days. 
 C hours. 
 
 ■mvaa 
 
 ^r. r. ^ 
 
 •IjSAODaa rH rH fH rt r-( r-trH 
 
 •s 
 
 e g 
 1 
 
 Trocar. 4th inter- 
 space. 
 
 Incision and trocar. 
 Cth interspace. 
 
 Trocar. 4th inter- 
 space. 
 
 Incision and trocar. 
 5th interspace. 
 
 Trocar. Cth inter- 
 space*. 
 
 Incision and trocar. 
 5th interspace. 
 
 Do. 
 
 Not stated. 
 Not stated. 
 Trocar. 5th inter- 
 space. 
 
 Incision. 
 
 •93v puB xas 
 
 M. 
 
 F. 35 
 M. 
 
 M. IG 
 
 F. 22 
 M. 23 
 
 M. 23 
 
 M. 27 
 
 Date. 
 
 184- 
 
 1852 
 1849 
 
 1854 
 
 1854 
 1855 
 
 1855 
 
 1856 
 1857 
 
 
 
 H 
 
 -« 
 
 s 
 
 H 
 
 a, 
 
 
 14, Kyber. 
 
 15, J. C. Warren. 
 10, Champouillon. 
 
 17, Jobert. 
 
 18, Behier. 
 
 19, Aran. 
 
 20, Aran. 
 
 21, Aran. 
 
 22, Skoda. 
 
 23, Vernay. 
 
 24, Trousseau- 
 
 25, Wilezkowski. 
 
88 
 
 PARACENTESIS OF THE PERICARDIUM. 
 
 o 
 ■ z 
 
 a 
 
 K 
 
 H 
 
 U 
 
 i 
 
 O 00 
 
 -■^ 
 
 .Ho 
 
 P. 
 
 M 
 
 go -OS - § oT 
 
 Lancet, June 12, 1869. 
 
 Bull, de I'Acadeniie 
 de Medicine, 1875, 
 p. 1273; Gaz. Hebd. 
 de Medeciue et de 
 Chirurg., 1868. 
 
 P.3 
 bio 33 
 
 tflCO o 
 
 a 
 
 .1 
 ■p. 
 S 
 o 
 
 1= 
 
 •St 
 
 ^ ° g s 1 s .a 
 ^ £ s o<a a a 
 
 Ph O 
 
 3 ^c.a'i 
 
 Ill ill 
 
 •< 
 
 
 ?3i 
 
 Hi 3 
 
 •a £ 
 
 11 
 
 n g 
 
 sa '^o *g-2a |£s|a'2s-2S.SsS^2" 
 
 , a.|} .11 :ij|J;l|;||| 
 
 M H H H S 
 
 a 
 
 2>:3' 
 2§ 
 
 •■ao\yai9io ^W 
 -Bj' ?Bq; 9UIIX 
 
 
 ^11 
 '"as 
 
 
 3 
 O 
 
 §3 
 
 •q^Bsa 
 
 
 ^ ^ ^ 
 
 iH iH 
 
 ^ 
 
 •.fj9Aooaa 
 
 rH 
 
 2 . 
 
 .• 6 
 
 id si- 
 
 a ^ .3 
 
 5 . ■3 
 
 O 3 05 "O 
 
 .2 2 
 
 «' i 1 » rt i 
 p §* e>-2 p S" 
 
 s s 
 
 p a 
 5 1 
 
 S cS 3 C8 
 
 a<- 
 
 iiil 
 
 •e3y pnB X9S 
 
 g 
 
 s 
 
 <M 00 rH 
 
 IH to r-1 
 
 c5 
 
 •* 
 ri 
 
 
 o 
 
 o So CO 
 
 OT g CO 
 ""I r-t >■* 
 
 
 OJ 
 
 PS 
 
 g 
 
 ■< 
 a 
 
 s 
 
 o 
 
 3 
 
 o 
 
 1 
 
 to '% to 
 
 6 §* 
 
 CO CO 
 
 1 
 t 
 
 CO 
 
TABLE OF CASES. 
 
 89 
 
 « 
 U 
 
 Bull. G6n. de Therap., 
 1871, tome Ixxx. p. 
 125. Dieulafoy on 
 Pneumatic Aspira- 
 tion, London, 1873, 
 p. 235. 
 
 Bull, de I'Academie de 
 Medecine (1875), t. 
 xl. p. 1216 ; also, id., 
 t. xxxvii. p. 658. 
 
 Bull, de I'Academie do 
 Medecine, 1875, p. 
 1276. 
 
 Dieulafoy on Pneu- 
 matic Aspiration, 
 Loudon, 1873, p. 241. 
 
 Complication. 
 
 Left pleuri- 
 tis. 
 
 Dilatation 
 and val- 
 vular dis- 
 ease of 
 heart. 
 
 Left pleuri- 
 tis. 
 
 Remarks. 
 
 800 grammes soro-pus. Passed 
 from notice after GO days, but 
 had symptoms of chronic 
 lung disease. On withdrawal 
 of needle found piece of car- 
 tilage in the end. 
 
 Intended to tap left pleura, as di- 
 agnosis was pleuritis and per- 
 icarditis. F. oz. xvj purulent 
 serum flowed, but autopsy 
 showed it had come from per- 
 icardium, and that pleura 
 was adherent. Eeporter 
 says that death must not be 
 attributed to the tapping. 
 
 At first no fluid, then blood 
 and serum, followed by pure 
 blood, apparently venous, 
 andnotinjets. 200 grammes. 
 Child became pale. Im- 
 provement followed. Peri- 
 carditis did not return. Death 
 occurred five months after 
 operation. Author says the 
 right ventricle was wounded. 
 
 First tapped left jileura, then 
 aspirated pericardium, and 
 withdrew 025 grammes se- 
 rum. Ten days later aspi- 
 rated pleura again, and in- 
 jected iodine. Sputa like 
 phthisis. 
 
 •noT'j'BJado sq? 
 psAiAans 1U9H 
 -TJi ?Bq} 8U1II 
 
 1 
 •a 
 
 •q^BBQ 
 
 f-l IH 
 
 ■jfjsAooaa 
 
 iH iH 
 
 .■id 
 
 CQ o 
 
 1 
 
 Aspiration. Too 
 much oedema to 
 count ribs. 
 
 Trocar. 5th inter- 
 space, four centi- 
 metres outside 
 nipple. 
 
 Aspiration. 6th in- 
 terspape. 
 
 Aspiration. 
 
 •83v puB xeg 
 
 a a a a 
 
 
 1870 
 1872 
 
 o 
 
 H 
 
 a 
 
 Ok 
 
 O 
 
 33, Ponroy(Fr6my). 
 
 34, Labric. 
 
 35, Boger. 
 
 36, Ghaillou. 
 
90 
 
 PARACENTESIS OF THE PERICARDIUM. 
 
 i 
 
 is 
 
 H 
 
 as 
 
 ■Sa-s 
 
 go's '' 
 
 Edinburgh Medical 
 Journal, Oct. 1872, 
 p. 376. 
 
 Bulletin de I'Acade- 
 mie do Mfidecine, 
 1872, tome xxxvii. 
 p. IMl. 
 
 Edinburgh Medical 
 Journal, June, 1872. 
 
 Practitioner, xi. 265. 
 
 Edinburgh Medical 
 Journal, March, 
 1875, p. 799. 
 
 British Medical Jour- 
 nal, June 19, 1875. 
 
 Lancet, Aug. 22, 1874, 
 
 p. 271. 
 Lancet, December 19, 
 
 1874. 
 
 
 
 "S, 
 
 6 
 
 "3.2 . 
 o 
 
 
 Diarrhoea 
 and 
 phthisis. 
 
 Pleurisy. 
 
 Plithisisand 
 tubercular 
 peritonitis. 
 
 Pleurisy and 
 abscess of 
 lung. 
 Peritonitis. 
 
 
 First tapping, 3 ounces pus. 
 Second operation, two days 
 after, %]/, ounces pus. Left 
 canula in sac, and washed 
 out with salt solution. Died 
 with cerebral symptoms. 
 Followed pneumonia of left 
 side. 
 
 1000 grammes serum. Tapped 
 pleura 1430 grammes. Died 
 in forty-nine days of diar- 
 rhtt'a and phtlii.^is. 
 
 Removed f. oz. xxxv. 
 
 Tapped pericardium twice, 
 f. oz. iij^ii and f. oz. vj. Last 
 time in 4th interspace. 
 Tapped abdomen twice. 
 
 Removed pus f. oz. xxx ; prob- 
 ably from rupture of pulmo- 
 nary abscess. 
 
 Tapped six times. Purulent 
 fluid. F. oz. xxj ; f. oz. xxxv ; 
 f. oz. Ix — iodine injected ; f. 
 oz. 1 — iodine ; f. oz. xxx ; f. oz. 
 XX (?) — iodine. 
 
 Acute rheumatic pericarditis, 
 oz. X. 
 
 Acute iheumatic pericarditis. 
 Removed f. oz. xiv. Walking 
 about in twenty-seven days. 
 
 ■uoi^BJsdo eq^ 
 paAiAjns inajt 
 -ua ?T!qi 81UJX 
 
 1 
 
 § 
 
 1 
 
 49 days. 
 
 6 days. 
 
 50 days. 
 
 Few hours. 
 38 days. 
 
 •q}B3a 
 
 ^ ^ r. r. ^ ^ 
 
 •jCjaAOoaa 
 
 I-( 1H 
 
 ■§1 
 a 
 
 Thiersch's syringe 
 at first. (Aspi- 
 ration.) Trocar 
 second operation. 
 Site not given. 
 
 
 Aspiration. 5th in- 
 terspace. 
 
 Incision and trocar. 
 
 5th interspace. 
 Aspiration. 3d and 
 
 4th interspaces. 
 
 Aspiration. 4th in- 
 terspace. 
 
 Aspiration. 5th in- 
 terspace. 
 
 Aspiration. 4th in- 
 terspace. 
 
 Aspiration. 4th in- 
 terspace. 
 
 •8Sy puB X8S 
 
 a 
 
 a 
 
 M. 23 
 
 M. 27 
 M. 6 
 
 M. 13 
 M. 13 
 
 M. 25 
 M. 20 
 
 1 
 
 
 fH 
 
 
 1872 
 
 1872 
 1873 
 
 1874 
 
 1874 
 
 1874 
 
 1874 
 
 g 
 
 M 
 B. 
 
 o 
 
 1 
 
 3 
 1-5 
 
 i 
 
 a 
 fi 
 oo* 
 
 CO 
 
 39, Chairou. 
 
 40, Maclaren. 
 
 41, Heath. 
 
 42, Saundby. 
 
 43, Gooch. 
 
 44, Steele. 
 
 45, Bartleet. 
 
TABLE OF CASES. 
 
 91 
 
 a 
 o 
 
 S5 
 
 a 
 a 
 a 
 
 a 
 K 
 
 Dublin Journal of 
 Medical Sciences, 
 June 1, 1870. 
 
 London Mod. Kecord, 
 Sept. 15, 1875, p. 532; 
 from Marseille Me- 
 dical. 
 
 Gaz. des Hopitaux, 
 1873, p. 1130. 
 
 Glasgow Medical 
 Journal, July, 1877, 
 p. 301. 
 New York Med. Rec- 
 ord, April 1, 1870, 
 J). 221 ; from Med. 
 Comm. of Connecti- 
 cut Med. Soc, 1875. 
 
 a 
 o 
 
 "H. 
 - I 
 
 6 
 
 a 
 Pa 
 
 Left plouri- 
 tis weeks 
 previously ; 
 endocar- 
 ditis. 
 
 Pneumonia 
 and pleu- 
 risy. 
 
 Pneumonia. 
 
 
 o 
 
 ■3 
 <S 
 > 
 
 Two syringofuls of serum. 
 Puncture did not close, fluid 
 became purulent, and flowed 
 for nearly six months. Fi- 
 nally closed spontaneously. 
 
 Taliped eight times at same 
 place. Serous ett'usion be- 
 coming hemorrhagic. Two 
 punctures of the heart with- 
 out accidents. Death fol- 
 lowed 3 days after eighth op- 
 eration. Intervals between 
 the operations wore 4 days, 3 
 days, 3 ilays, 4 days, 7 days, 7 
 days, 3 days. Autopsy showed 
 noai-ly 800 grammes of choc- 
 olate-colored fluid in jiericar- 
 dium. No syncope or aggra- 
 vation seemed to follow the 
 punctures of tlie heart, 
 though 80 grammes and 30 
 grammes of blood wore with- 
 drawn. 
 
 Tapped three times. Oz. xx se- 
 rum ; 15 days later, oz. xxx ; 
 11 days subsequently, oz. xv. 
 
 Tapped twice at interval of 7 
 days. Oz. xxxii and oz. iss 
 pus. 
 
 
 i 
 
 -a 
 
 1 
 
 29 days. 
 9 days. 
 
 •ti^Bsa 
 
 iH 
 
 i-l 
 
 iH r-l 
 
 •.fa9A008a 
 
 IH 
 
 
 K 
 
 a' »■ 
 
 .2 S 
 
 If 
 < 
 
 Aspiration. Most 
 projecting point. 
 
 Aspiration. 5th in- 
 terspace. 
 
 Aspiration. 5th in- 
 terspace. 
 
 Trocar. 5th inter- 
 space. 
 
 •eSy pnB xag 
 
 
 ^ 
 
 a S 
 
 M. 23 
 M. 31 
 
 i 
 4 
 
 o 
 
 CO 
 
 p-t 
 
 1873 
 1873 
 
 1874 
 1874 
 
 i 
 
 O 
 
 a' 
 o 
 
 o" 
 •* 
 
 47, Villcueuve. 
 
 48, Bouchut. 
 
 49, Maclood. 
 
 50, Lyon. 
 
92 
 
 PARACENTESIS OF THE PERICARDIUM. 
 
 o 
 
 a 
 
 H 
 
 a 
 P5 
 
 London Med. Record, 
 iii. p. 275 ; from Gi- 
 ornale Veneto di 
 Scienze Mediche, 
 
 1875. 
 
 Trans. State Med. So- 
 ciety of Aikansas, 
 1875-76; quoted in 
 American Journal 
 of Med. Sciences, 
 January, 1877, p. 
 190. 
 
 Lancet, January 8, 
 1875, p. 50; Trans. 
 Bristol (England) 
 Med. Chirurg. Soci- 
 ety, vol.i., 1878, p. 75. 
 
 New York Medical 
 Record, February 
 12, 1876, p. 110. 
 
 L'Union M^dicale, 25 
 rev., 1879, p. 315. 
 
 g 
 
 H 
 
 ■p. 
 
 1 
 6 
 
 •E-3 
 
 |i 
 
 Pleuritis 
 when at- 
 tack be- 
 gan?; 
 
 Chronic 
 cardiac 
 disease. 
 
 Pleurisy. 
 
 Right pneu- 
 monia. 
 
 
 Paracentesis of chest twice, and 
 abdomen once, previously. 
 Oz. X fluid from pericardium. 
 Subsequently pleura tapped 
 
 again. 
 
 Oz. xxviii pus. Great relief. 
 Respirations fell from 60 to 
 28. Patient was so much ex- 
 hausted the operator did not 
 operate a second time, 
 though he considered the 
 question. 
 
 Oz. xlii serum. Left hospital in 
 ten weeks greatly improved. 
 Several months later was in 
 hospital again with cardiac 
 symptoms, but there was no 
 indication of fluid in the per- 
 
 icardium. 
 
 Oz. xxx pus. After death found 
 oz. xxxvi in pericardium. 
 Pericardial effusion probably 
 developed by admission of 
 pleuritic effusion through a 
 minute opening. 
 
 Tapped twice. Pus 43 grammes. 
 Next day used laige trocar 
 and pump because fluid so 
 thick. Pus and clots 140 
 grammes. Left canula in 
 place, intending to inject 
 iodine, but did not do so. 
 
 psAiAjns ?nsn 
 
 1 
 
 1 
 
 lO 
 
 22 hours. 
 
 •q^Baa 
 
 IH 
 
 Hi 
 
 IH T-t 
 
 •jCjBAOoaa 
 
 rH 
 
 o 
 m 5 
 
 i* 
 
 1 
 
 i. 
 
 o a) 
 
 +^ C3 
 
 •3 & 
 
 a S 
 a a 
 
 O — ' 
 
 is 5 
 
 M 
 
 Aspiration. 4th in- 
 terspace. 
 
 Aspiration. 5th in- 
 terspace. 
 
 Aspiration. 
 
 Aspiration. 4th in- 
 terspace ; 2d oper- 
 ation trocar, 4th 
 interspace. 
 
 •BSy pnB X9S 
 
 
 M. 45 
 M. 60 
 
 — 13 
 
 M. 22 
 
 i 
 
 00 
 
 I-l 
 
 1875 
 1875 
 
 1875? 
 1876 
 
 OS 
 
 o 
 
 -1 
 
 H 
 
 o 
 
 a 
 
 o 
 
 52, Welch. 
 
 53, Elliott (Burder). 
 
 54, J. Lewis Smith ? 
 
 55, Viiy. 
 
TABLE OF CASES. 
 
 93 
 
 a 
 a 
 a 
 
 a 
 
 ■p 
 
 Medical News and Li- 
 brary, March, 1878, 
 and Ameri<-an Jour- 
 nal of Med. Sciences, 
 April, 1879. 
 
 Trans. Detroit Medi- 
 cal and Library As- 
 sociation, January, 
 1879. 
 
 New York Medical 
 Record, July, 1878, 
 p. 45. Letter from 
 operator. 
 
 Letter from operator. 
 
 a 
 
 % 
 
 a 
 5 
 
 1^ 
 
 a > 
 2<2 
 
 Albuminuria 
 and casts ; 
 due to eS'u- 
 sion in per- 
 icardium. 
 
 Pulmonar;' 
 disease ? 
 
 Pleuritis 
 and ana- 
 sarca. 
 
 Hypertrophy 
 of heart. 
 
 •< 
 
 Few drachms. At autop.sy per- 
 icardium contaiuod oz. .\iv. 
 Near puncture firm adliesion 
 to heart, which may account 
 for small amount of fluid ob- 
 
 tamed. 
 F. oz. viij serum. Aide to get 
 out of bed 20 days after oper- 
 ation. Pleuritis and ascites 
 314 months subsequently. 
 Death occurre<l 15 months 
 after operation. Autopsy 
 showed complete adhesion, 
 no valvular lesion, fatty de- 
 generation of muscular 
 
 structure. 
 F. oz. liv pus. Living when 
 case reported 30 days subse- 
 quently. Expectorates pur- 
 ulent matter, though his 
 condition is far better than 
 
 at operation. 
 
 F. oz. i soro-sanguinolent fluid. 
 Much relief. S\ibsequently 
 tajiped right pleural cavity 
 twice. Died several months 
 after with general dropsy. 
 0.j fluid in pericardium. 
 
 Fluid drachm ss (?) Great re- 
 lief; due probably to grad- 
 ual escape offluid into tissues 
 around pciricardium. 
 
 
 1 
 
 
 
 1 
 
 1 •iH'Kaa 
 
 - 
 
 
 
 - 
 
 1 '^jaAooaa 
 
 
 iH 
 
 f-< 
 
 IH 
 
 ii 
 
 IS 
 
 a a 
 
 it 
 
 a 
 
 a o 
 •2 '4 
 
 _a 
 
 •2 § 
 
 ■|i 
 
 Hypodermic syr- 
 inge. (Aspiration.) 
 4th or 5th inter- 
 space. 
 
 Hypodermic needle. 
 4th interspace. 
 
 •say pu« xsg 
 
 o 
 ^ 
 
 
 •* 
 s 
 
 M.50 
 M. 22 
 
 Date. 
 
 5 
 
 i-H 
 
 i 
 
 00 
 
 1878 
 1879 
 
 Operator. 
 
 a 
 
 a 
 
 o 
 
 1 
 
 US 
 
 i 
 
 To 
 
 o 
 
 69, Porchor. 
 
 CO, Comogys Paul. 
 
94 PARACENTESIS OF THE PERICARDIUM. 
 
 RESULTS OF THE OPERATION. 
 
 In preceding chapters I have considered the indications 
 for performing the operation of paracentesis of the peri- 
 cardium, have discussed the various methods recom- 
 mended, have given my views as to the claims of the 
 numerous points of puncture proposed, and have devoted 
 some space to discussing the objections urged against the 
 procedure. It now remains to study the table of opera- 
 tions placed at the beginning of this chapter, in order to 
 see what are the results that have been obtained, and that 
 we may expect to obtain, from the performance of para- 
 centesis of the pericardium. 
 
 In the table there are recorded 60 cases of the opera- 
 tion.* Of these, there were 
 
 Males 43 
 
 Females 12 
 
 Sex not mentioned ........ 5 
 
 It may be interesting to study the relation of the oper- 
 ation and the ages of the patients so treated : 
 
 The cases under twenty years (inclusive) numbered . 20 
 " over twenty years numbered . . . .25 
 
 " whose age was not given numbered . .15 
 
 The greatest age at which tapping was done was sixty- 
 eight years, and the patient in this instance (No. 28) was 
 a female, who was operated upon twice. It is deemed 
 worthy of notice that this is apparently the only time that 
 
 * McCall Anderson recently aspirated the pericardium of a boy, aged 
 seventeen years. Great improvement followed; but the report was made 
 just after the operation, and it is not possible to state the result. See 
 Glasgow Medical Journal, September, 1879, p. 216. 
 
RESULTS OF THE OPERATION. 95 
 
 the puncture was made on the right side of the sternum. 
 It has previously been stated that this side has quite 
 recently been suggested as the most available spot. The 
 youngest patients were those of Roger (No. 35) and Yil- 
 leneuve (ISTo. 47), who were five years of age. 
 
 In all branches of medicine the main question that arises, 
 when a line of action is advocated in therapeutics, is this : 
 "What is the ratio of recovery ? This query I now attempt 
 to answer : 
 
 The recoveries were ....... 24 
 
 " deaths were 36 
 
 Total 60 
 
 It will be observed that I have included under the head- 
 ing of fatal cases the patient operated on by Jowett (No. 4), 
 where it is stated that there was a " hope of recovery." 
 This is done, because I do not wish the statistics to give a 
 more favorable view than is just. There are few probably 
 who distrust statistics as much as I do, since so much 
 depends on the accuracy and non-partisanship of the 
 reporter. Especially is this the fact when a man reports 
 a number of cases occurring in his own practice. That 
 unknown quantity, the " personal equation" as to diag- 
 nostic skill, accuracy, and veracity, satiates, to my mind, 
 the great majority of such results. Hence I have endeav- 
 ored in compiling these statistics to lean towards the side 
 of the unbeliever, rather than to make too fair a showing 
 for my side of the question. 
 
 Taking, then, the recoveries as twenty-four, and the 
 deaths at thirty-six, we have 40 per cent, as the average 
 of recover}', or 60 percentage of mortality. This average 
 is certainly a good one, when the almost always fatal re- 
 sult of expectant treatment is remembered. If the fluid 
 be not evacuated, the quantity increases until pressure 
 
96 PARACENTESIS OF THE PERICARDIUM. 
 
 upon, and maceration of, the heart, as well as the injurious 
 tension to which the surrounding intra-thoracic structures 
 are subjected, cause the death of the patient after most 
 distressing symptoms, with five pints* or more of pus in 
 the enormously distended sac. 
 
 The mortality after tracheotomy in croup in the St. 
 Eugenie Hospital is, according to Barthez,t about 66| per 
 cent., and the number of cases that die after herniotomy 
 is certainly great; yet these operations are accepted as 
 justifiable. Why, then, should one hesitate to tap the peri- 
 cardium in large effusions, when the fatality of let-alone 
 treatment is fully recognized ? The mortality of 60 per 
 cent, is certainly better than that mentioned above as fol- 
 lowing tracheotomy. A man who would open a child's 
 trachea in a trice for croup, would in many cases, I fear, 
 let that child's father die with pericardial effusion, because 
 he dare not tap the pericardium, and thus remove the 
 agent preventing the proper oxygenation of blood as effect- 
 ually as the membrane in the child's larynx. The mor- 
 tality in paracentesis pericardii, given above, is inclusive 
 of all cases found in the table, but very many of the pa- 
 tients had serious diseases complicating the pericardial 
 effusion. Of the thirty-six who died, there were thirty-one 
 who are known by us to have had other concomitant and 
 often incurable disease. In the five remaining instances 
 there was no other disease, or at least none mentioned. 
 This would give the astonishing result of only five cases 
 of death from uncomplicated pericardial effusion in a series 
 of sixty cases of operation. 
 
 Let us look, however, at the results of the operation in 
 recent times only, for the earlier cases cannot be scruti- 
 
 * Boston Medical and Surgical Journal, February, 1866, p. 29. 
 f Atkin's Practice of Medicine, 2d American ed., vol. ii. p. 998. 
 
RESULTS OF THE OPERATION. 97 
 
 nized witli as miicli tlioroiighness as desirable, and, more- 
 over, do not give as minute details as I wisli to obtain. 
 To avoid tlie influence of sucli cases as Romero's, Kyber's, 
 Aran's, and Beliier's, whose authenticity has been ques- 
 tioned and cannot be absolutely proved at this period, I 
 shall take the cases that have occurred since 1860. In 
 this number I include the fatal cases of Chaillou and La- 
 bric, whose dates I have not obtained, since it is probable 
 that the operation was performed after 1860. The record 
 will then stand as follows : 
 
 Since 18G0 there have been . . . .10 recoveries. 
 " "".... 25 deaths. 
 
 Total 35 cases. 
 
 This gives a mortality of 71.42-f per cent. In the tw^enty- 
 five instances where death occurred subsequent to the 
 tapping, serious disease is stated to have existed in all 
 the cases except three (Nos. 31, 34, and 38). In other 
 words, out of the whole thirty-five cases operated upon, 
 there were thirteen cases of pericardial effusion where 
 other diseases did not seem to act as a complication, and 
 of these ten recovered and three died. This would give a 
 mortality of 23+ per centum. 
 
 By looking over the whole table it will be seen, as 
 stated on page 79, that the average time of survival of 
 those who are known to have lived beyond the first day is 
 over twenty-seven days, which is equivalent to the asser- 
 tion that those who are not actually moribund, and who 
 survive the shock of operation, have a probable prolonga- 
 tion of life of nearly four weeks. 
 
 Thus, then, I have gleaned from the long list of cases 
 the facts seeming to me most important, and by elimi- 
 nating disturbing factors have presented a statement meant 
 to be impartial. I am undoubtedly an advocate of the 
 
98 PARACENTESIS OF THE PERICARDIUM. 
 
 operation in selected cases, and may have unconsciously 
 misrepresented the views of others, or unduly assumed 
 that my side of the question was the correct one. If I 
 have done so, I must regret it, for no scientific progress is 
 to be expected until writers step outside of self and weigh 
 pro's and con's with an assayer's balance. 
 
 Surely the record I have given supports the plea for the 
 adoption of paracentesis of the pericardium into the family 
 of accepted surgical procedures ; surely it is noble to add 
 three or four weeks to the life of a fellow-being. What 
 care I if you call it a palliative operation, forsooth ! Do 
 we not excise carcinomatous breasts ? Does not every one 
 tap ascitic bellies, when cirrhotic liver exists, for pallia- 
 tion ? Would you withhold opium from a groaning pa- 
 tient because it did not extirpate the disease ? Who is to 
 estimate the value of one week added to the life of a Csesar? 
 A perfect hip-joint is not expected after chronic coxitis, 
 neither must a perfect heart be looked for after chronic 
 pericarditis. Let the operation be palliative, if you will; 
 but operate, and that before continuance of inflammation, 
 maceration of the heart, and pressure of the distended sac 
 have caused the tissues to assume pathological aspects of 
 such a kind that a perfect return of function is impossible. 
 
IISTDEX. 
 
 Adhesion, pericardial, 79. 
 Anatomy of parts concerned, 40. 
 Apex beat, position of, 21. 
 Area of dulness, 24. 
 Artery, internal mammary, 71. 
 Aspiration, advantages of, 49. 
 Aspirator, best form of, 53. 
 Auscultation a means of diagnosis, 28. 
 
 B. 
 
 Bright's disease a result of effusion, 46. 
 Bulging a sign, 20. 
 
 Capacity of normal pericardium, 15. 
 Causes of pericardial effusion, 9. 
 Complications, 82. 
 Complications, treatment of, 82. 
 
 D. 
 
 Dangers to be encountered, 71. 
 Death after operation, case of, 75. 
 Deaths, 95. 
 Diagnosis, 29. 
 Diagnosis, errors of, 30, 33. 
 Dilatation, diagnosis of, 31, 
 Drainage in pericarditis, 56. 
 Dulness, area of, 24. 
 Dulness, factors producing, 23. 
 Dulness in fifth right interspace, 23. 
 Dulness, Botch's experiments on, 25. 
 Dulness, triangular, 25. 
 
 Effusion becoming purulent, 80. 
 Effusion, post-mortem, 9. 
 
 Fistula, pericardial, 83. 
 Fitch's trocar, 50. 
 Friction sound, 28. 
 
 H. 
 
 Hfemo-pericardium, 16. 
 Heart, wound of, 73. 
 Heart, wound of (cases), 73. 
 Hemorrhagic effusion, 13. 
 History of paracentesis, 38. 
 Hydro-pericardium, 34. 
 Hypertrophy, diagnosis of, 30, 32. 
 
 I. 
 
 IiI?pection a means of diagnosis, 20. 
 
 Internal mammary artery, 71. 
 
 Internal mammary artery, hemorrhage 
 from, 72. 
 
 Intra-thoracic growths a cause of peri- 
 carditis, 12. 
 
 Iodine, injection of, 54. 
 
 K. 
 
 Kidney disease a complication, 46. 
 
 M. 
 
 Method of operating, best, 67. 
 Methods of operating, 49. 
 
 99 
 
100 
 
 INDEX. 
 
 Mortality, 95. 
 Myocarditis, 35. 
 
 N. 
 
 Nomenclature of pericardial eifusions, 
 
 16. 
 
 0. 
 
 Objections to the operation, 77. 
 Operating, best method of, 67. 
 Operation, a palliative, 77. 
 Operation, cases suitable for, 44. 
 Operation, repetition of, 81. 
 
 P. 
 
 Palpation a means of diagnosis, 21. 
 Paracentesis, death after, 75. 
 Percentage of recovery, 95. 
 Pepper's trocar, 52. 
 Percussion a means of diagnosis, 22. 
 Pericarditis, hemorrhagic, 13. 
 Pericarditis, idiopathic, 10. 
 Pericarditis, inflammatory, 10. 
 Pericarditis, purulent, 13. 
 Pericarditis, purulent, treatment of, 55. 
 Pericarditis, secondary, 10. 
 Pericardium, anatomy of, 40. 
 Pericardium, limits of, 42. 
 Physical signs, 20. 
 Pleura, relations of, 43. 
 Pneumo-hydro-pericarditis, 47. 
 Point of puncture, 58. 
 Point of puncture, best, 66. 
 Points of puncture recommended, 59. 
 Post-mortem effusion, 9. 
 Precautions, 68. 
 Prognosis, 34. 
 
 Quantity of fluid, 14. 
 
 R. 
 
 Reaccumulation of fluid, 80, 81. 
 
 Recoveries, 95. 
 
 Repetition of operation, 81. 
 
 Results, 94. 
 
 Results since 1860, 96. 
 
 Roberts's trocar, 51. 
 
 Rotch's experiments, 25. 
 
 Secondary operations, 81. 
 Signs, physical, 20. 
 Statistics, 94. 
 Statistics since 1860, 96. 
 Suitable cases, 44. 
 Survival, time of, 78. 
 Symptoms, objective, 18. 
 Symptoms, subjective, 17. 
 
 Table of cases, 84. 
 Time of operation, 48. 
 Treatment, medical, 36. 
 Treatment, surgical, 49. 
 Treatment of complications, 82. 
 Trephining the sternum, 49. 
 Triangular area of dulness, 25. 
 Trocar, Fitch's, 50. 
 Trocar, Pepper's, 52. 
 Trocar, Roberts's, 51. 
 
 Varieties of fluid eifused, 12. 
 Venous pulsation a symptom, 19. 
 
 W. 
 
 Wound of heart, 73. 
 Wound of heart, cases of, 73. 
 

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 Paracentesis of the pencardjunv 
 
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