[50] Borchardt has collected 83 cases of operations upon the heart, of which 78 included heart suture. Of these 78, 46 died and 32 recovered. He quotes a statement of Billroth, made when this surgeon was sixty years of age: “Paracentesis of the pericardium is an operation which, according to my view, closely approaches to what might be considered a prostitution of surgical art, or, as some surgeons would call it, a surgical frivolity, an operation which altogether has more interest for the anatomist than for the physician. Possibly a later generation will regard it differently. Internal medicine is constantly becoming more surgical, and those physicians who concern themselves especially with internal medicine will find themselves compelled to make the most daring operation.” The rapid advances made in surgery during the past three decades cannot be better illustrated than by contrasting Billroth’s statement of a few years ago with the standard practice of today.
Pericarditis, either of idiopathic or traumatic origin, may produce a degree of distention, either hydropericardium or pyopericardium, calling for surgical intervention—in the former case with the aspirating needle, in the latter either with the needle or the knife. When a pericardium is greatly distended with fluid there is marked change in the position of the apex beat, with embarrassment of heart action, accompanied by distress and distention of the veins of the upper part of the body, as well as much alteration of the ordinary physical signs, the area of dulness being correspondingly enlarged and the lung sounds being lost over the area occupied by the distended sac. Great distention, with marked precordial trouble and distress of heart and lung function, always requires paracentesis.
Paracentesis pericardii is performed ordinarily by puncturing (a previously sterilized area) 3 to 5 Cm. to the left of the left border of the sternum, and in the fifth intercostal space, with a sterilized needle. Here are found the internal mammary artery and the pleura. Too rapid withdrawal of fluid may lead to syncope. It should, therefore, be allowed to escape slowly. Should it prove purulent it may be incised, passing the knife-blade along the needle; or the sac may be emptied, when, if fluid re-collect, a free incision should then be made. Roberts has shown that recovery follows in at least 40 per cent. of cases of empyema of the pericardium thus treated. Gauze drainage may be provided, but irrigation of the cavity should not be practised.
Allingham has suggested to open the pericardium from below by an incision three inches in length, carried along the lower margin of the seventh left costal cartilage, to separate the cartilage from the abdominal muscles, pull outward and upward the lower surface of the diaphragm, expose the cellular interval between its attachment to the cartilages and to the tip of the sternum, to expose and enlarge by blunt dissection, until there appears a mass of fat which belongs above the diaphragm in the interval between the pericardium behind, the sternum in front, and the diaphragm below. When this is removed the pericardium is exposed and can here be opened. Throughout the procedure injury to the pericardium which lines the upper surface of the diaphragm should be avoided. By this method the pleura need not be opened and better drainage may be secured. (Dennis.)
Abscess in the heart wall is an exceedingly rare lesion, usually accompanying pyopericardium, but occasionally met without it. It was the writer’s experience in one case, in puncturing for what was supposed to be a pyopericardium, to withdraw pus and give temporary relief. Later postmortem examination showed that this pus came from a large abscess in the wall of the heart, which had been thus entered by the aspirating needle without immediate bad consequences, but, on the contrary, with temporary relief.
THE LUNGS.
In the fact that the lung never completely fills the pleural cavity we find explanation for the kindred fact that small effusions produce little if any compression symptoms. Collapse of one lung after opening the chest is never complete if the other lung be uninjured and functionating. Moreover, a partial collapse on the affected side will be quickly atoned for when the pressure of the external atmosphere is taken off.
Two or three serious pathological conditions of the lung occasionally require surgical intervention.
HYDATIDS OF THE LUNG.
Hydatids of the lung have been mentioned (see above). Seventy-five per cent. of these cases terminate fatally without surgical help, and in reality more prospective benefit can be offered by it than without it. Serious and even fatal collapse has attended the sudden withdrawal of fluid from hydatid cysts in this location. Aspiration may be made, but even this is scarcely less dangerous while it is less satisfactory than free exposure and drainage.