The fourth (Porter), fourth and fifth (Roberts), or fifth and sixth (Delorme) costal cartilages near the sternum may be resected, the pleura and the internal mammary artery being drawn toward the left, and the pericardium thus exposed.
It is clearly the duty of the surgeon, whenever death is imminent from cardiac pressure, to resort to tapping. The oper ation is not attended with great danger, and in cases of effusion from rheumatic pericarditis there is every prospect of re covery. A. Meldon (Brit. Med. Jour., Dec. 12, '96).
Further evidence adduced in favor of personal contention that pericardial effu sions should be treated in the same man ner as pleural effusions, paracentesis being insufficient to cure suppurative pericarditis. Incision and drainage are essential, and should be executed as soon as the diagnosis of pus in the pericar dium is made. The diagnosis of the purulent character of the effusion is de terminable only by exploratory punct ure. This should be done at the upper part of the left xiphoid fossa, close to the top of the angle between the seventh cartilage and the xiphoid cartilage. Periearcliotomy should then be done after resection of the fourth and fifth costal cartilages, raising a trap-door of these cartilages and using the tissues of the third interspace as a hinge. The mammary vessels and pleura are thus exposed and pushed to the left. The prognosis is good after pericardiotomy for pyopericardium. List of 26 collected cases showing 10 recoveries and 16 deaths. Of the fatal cases, 9 were septic, and all the others which died had com plicating lesions,—pulmonary, cardiac, or renal. J. B. Roberts (Med. News, May 8, '97).
Study of the anatomy of the parts upon 100 cadavers, showing that beneath the sternum there is always an area of cellular tissue with definite boundaries. There is an expansion of this cellular space at its superior and inferior por tions which are connected by a more or less constricted link. The inferior por tion lies beneath the costo-sternal junc tion of the sixth and seventh ribs, and a portion of the sternum adjacent thereto. The lower boundary corresponds to the base of the pericardium. By removing this portion of the sternum and sections of the sixth and seventh ribs at their costo-sternal junction the safest and surest approach to the pericardium is obtained. At this point there is no dan ger of injuring the diaphragm or pleura, and the internal mammary, lying to the outer side, can be avoided. The guide
to the incision should be the tubercle of the left sixth sterno-eostal articula tion. The incision should be parallel to the axis of sternum, about six or eight centimetres long, and should traverse the tubercle of the sixth rib at its junction with the sternum. Voinitch-Sianojensky (Revue de Chin, Nov. 10, TS).
Pericardotomy is indicated in all cases of suppurative pericarditis. Because of the uncertain and varying relations of the pleura, and because of the anterior position of the heart, whenever the peri cardial sac is distended by fluid, aspira tion of the pericardium is a more danger ous procedure than open incision when done by skilled hands. Incisions of the pericardium can be done quickly and safely by resection of the fifth costal car tilage, and in many cases under local anmsthesia. In many cases of serious effusion open incision without puncture will offer less risk and speedier cure than aspiration. C. B. Porter (Boston Med. and Surg. Jour., Oct. IS, 1900).
Chronic Adhesive Pericarditis (Ex ternal Pericarditis ; Pleuro-pericarditis; Mediastino-pericarditis).
The obliteration of the pericardial sac may not embarrass the heart's action in any important degree. If, however, the adhesions are formed at a time when the heart is dilated, the heart cannot easily regain its normal size, and is apt to come incompetent. If the external sur face of the pericardium, as well as the ternal, forms unnatural adhesions, the condition is far more serious.
Diagnosis. — In many instances in ternal adhesions are not capable of onstration, although they may be sus pected if there is rapid heart-failure after an attack of pericarditis. External sions may cause abnormal motions of the thoracic walls. Systolic retraction of the thorax in the neighborhood of the beat is particularly characteristic; there may also be an epigastric retraction, and one at the seventh and eighth ribs near the left edge of the sternum. It has also been stated that laterally and posteriorly there may be a similar systolic depression at the base of the left chest. In some cases the pulses paradoxus is produced, namely: the radial pulse becomes feebler or intermits with every inspiration.