TUMORS OF THE HEART.
Primary malignant tumors of the heart are very rare. Secondary and metastatic manifestation are much more frequent. True primary sarcoma has been repeatedly observed, and, with the exception of endothelioma, is practically the only primary cancer that could appear in this location. Carcinoma is found only as a secondary deposit, with which, however, the heart may become so involved as to permit of terminal rupture.
THE PERICARDIUM.
This closed sac is interesting to the surgeon in cases where it becomes filled with air; with blood, as the result of [injury] (see above); with fluid, as in acute pericarditis, or with pus, as a later stage of the latter, with its consequent pyopericardium. With the introduction of the aspirating needle it is possible to draw off collections of serum or pus, and paracentesis of the pericardium is now a conventional minor operation. It is managed in the same way and with the same instruments as when the pleural cavity is involved. It is ordinarily safe, and affords much relief.
The surgeon may go even farther than this and practise cardicentesis, as the writer did once by accident while hospital interne. After introducing the needle and withdrawing three or four ounces of pus he discovered that he had given great relief, which, however, was only temporary. The autopsy two days later revealed that he had passed the needle point through the pericardial sac into the heart wall and had tapped the abscess therein. This was in 1877, and was probably the first time that the heart wall was ever thus entered.
Now the operator goes still farther than this and practises intentional cardicentesis in cases of engorgement of the right side of the heart connected with lung disease which is threatening death from dyspnea with an overstrained heart. In such cases the needle may be introduced just above the fourth rib, from one-half to one inch to the right of the sternum, or entrance can be effected just above the fifth rib in an upward direction. From 100 to 250 Cc. of blood may be withdrawn.
For ordinary tapping of the pericardium the needle is inserted two inches to the left of the median line and in the fourth or fifth left interspaces, pushing it carefully until resistance is no longer felt and fluid flows through the tube. For either of these purposes the patient should be recumbent, unless the distress in this position is too great, in order that the heart may fall away from the chest wall. Aspiration can be repeated in case it gives relief. Little or no harm seems to ensue from the wound which a needle-point will make upon the heart substance. As the sac is progressively emptied the needle-point should be gradually withdrawn. When aspiration, exploratory or therapeutic, reveals the presence of pus, the well-known rule will apply, i. e., that pus left to itself will do more harm than will the surgeon’s knife. For pyopericardium there is but one successful treatment when aspiration fails, and that is open incision and drainage. This is not so severe a measure as exposure of the heart, as it may not even require the removal of one costal cartilage, although it would probably be better to take out at least one, since the shape of the pericardial cavity will change to such an extent after it is emptied as to raise the opening to a higher level than is given it at first. Open incision, then, with drainage, in these cases is no longer an experiment but a life-saving procedure. It will prove successful in at least half of the cases, which otherwise would certainly perish without it.
PNEUMOPERICARDIUM.
Pneumopericardium implies the presence of air in the pericardial sac, a condition of which there are now about 40 cases on record. The air nearly always enters through an ulcerative perforation from adjoining parts or through a wound, yet in 5 of these cases no opening could be found. In these it was probably due to the presence of a gas-forming bacillus, such as may also cause pneumothorax under certain circumstances. The perforation was in the esophageal wall in 7 cases, in 4 cases it was the result of softening of a lymph node, while in other instances it has followed abscess of the left lobe of the liver, pleuropneumonia and gastric ulcer perforating through the diaphragm. Of the 8 cases of penetrating wound from without, I included the small puncture made by paracentesis, while in 7 cases there had been fracture of the ribs or the sternum, with wound or laceration of the lung or the pericardium.
The most characteristic sign is a splashing, gurgling sound, synchronous with the heart beats, such as the French have called the “water-wheel bruit.” These sounds are louder than in hydropneumothorax, and are heard distinctly over the heart. The area of precordial dulness will change with position.