Coronary occlusion simulating an acute abdominal emergency

CORONARY OCCLUSION SIMULATING ACUTE ABDOMINAL EMERGENCY J.

M. T.

FINNEY,

CHARLES

JR., F.

M.D.,

MOHR,

F.A.C.S.

AN

AND

M.D.

BALTIMORE, MD.

A

PATIENT was sent into the hospita1 with the story that about six hours previousIy whiIe carrying a heavy Ioad he experienced a sudden sharp pain in the epigastrium, in fact, he thought he had been shot, and cohapsed immediateIy. His feIIow workmen thought he was dying, but got him into an automobiIe and took him to his home, severa miIes distant over a bad road. By this time he had revived somewhat, but cohapsed again whiIe being taken out of the automobile. The famiIy doctor saw him about two hours after the onset, at which time the patient was in moderate shock, with subnorma temperature, moderateIy rapid pulse, and compIaining bitterly of pain in the epigastrium. The abdomen was everywhere boardlike. He was given a quarter grain of morphia hypodermicahy, folIowed in about an hour by a second simiIar dose. While the abdomen still remained rigid, the pain was somewhat reIieved thereby. Inasmuch as he had a previous history of some indigestion over a period of several years, he was sent into the hospita1 by ambuIance with a tentative diagnosis of ruptured ulcer. On admission there presented a weII-nourished, heaviIy muscIed man of about fifty in quite acute distress and moderate shock. AI1 of his pain was referred to the epigastrium. The abdomen was quite rigid and boardIike from the umbiIicus upward; beIow that IeveI it was somewhat softer, but stiI1 very spastic. The point of most acute tenderness was aIong the Costa1 margin just to the right of the midIine. There had been some nausea, but no vomiting. The purse was 104, of fair voIume, regular in force and rhythm. BIood pressure IZO/~O; temperature 102.6%. rectaIIy. The white count was 19, IOO with 93 per cent poIymorphonucIears. Lungs clear on percussion and auscuItation; norma heart sounds and cardiac duIness. Urine normaI. A diagnosis of ruptured duodenal uIcer was made, but inasmuch as it had occurred on a presumabIy empty stomach, over five hours after a rather light lunch, and inasmuch as the rigidity of the Iower abdomen appeared to be reIaxing somewhat, and rectal examination was negative, it was thought that the hoIe had probabIy been seaIed over by omentum, and it might be we11 to wait unti1 the process had Iocahzed and waIled off more secureIy in the upper abdomen; therefore, 629

630

J. M. T. FINNEY,

JR.,

AND CHARLES

F. MOHR

it was decided to defer operation for the time being. ApparentIy this was good judgment, as the foIIowing morning the symptoms had subsided markedIy, the rigidity being confined entirely to the upper abdomen, though the temperature, bIood pressure, and puIse rate remained about the same. There was stiI1 marked tenderness on paIpation in the right upper quadrant. Operation was again deferred, and the following day he was so much better that he wanted to get up. An .y-ray taken to see if there was any evidence of free gas under,the diaphragm was reported negative, with norma Iung shadows and cardiac stripe. The spasticity of the upper recti had aImost disappeared except in an area just beIow the Costa1 margin on the right side. That night the nurse saw him at midnight and he was fine; twenty minutes Iater when she Iooked in again to see if he had gotten back to sleep, she found him gasping, and he died before the interne couId be caIIed. At autopsy the abdomina1 findings were enti;eIy negative, a perfectIy norma gaII bIadder, stomach, pylorus, and duodenum; no sign of any present or past troubIe. The chest was otherwise, the pericardium being tremendousIy distended with fresh bIood cIot. The heart was compressed. On the posterior surface of the Ieft ventricIe, near its apex was a ragged hoIe, which wouId admit the tip of a finger, situated in the center of an area of softened, recently infarcted muscIe about the size of a silver doIIar. On dissecting out the coronary arteries many atheromatous pIacques were encountered, with scarred areas in the heart muscIe indicative of previous smaI1 infarctions.

We at Ieast had shown good judgment in deferring operation, though on an entireIy wrong diagnosis and reasoning. We shuddered, and yet were at a Ioss, even Iooking back over the case, to see how we couId have recognized the actua1 condition. Not Iong thereafter, we were caIIed in by a confrere, a prominent gastroenteroIogist, to operate on his uncIe. He had previousIy been a patient of ours, and this was his eighteenth admission to the hospita1 over a period of tweIve years. He had originaIIy had a carcinoma of the cheek, which had been treated eIsewhere with x-ray and radium, resuIting in an extensive sIough of the soft parts and necrosis of the mandibIe. The previous admissions had been for operations on the jaw, and pIastic repairs to the soft parts. During these years of observation and many admissions, there was some mention of miId indigestion at times, but nothing more. There had been numerous genera1 anesthetics administered. The bIood pressure readings ranged from I IO to 138 systoIic, and 64 to 80 diastoIic. The present attack, as described by his nephew, who had sent him into the hospita1 for immediate operation,

CORONARY

OCCLUSION

AND

ABDOMINAL

EMERGENCY

631

sounded typica of an acute gab-bladder attack. His tentative diagnosis was “acute choIecystitis, possibIy perforated, with probable acute pancreatitis.”

I first saw the patient

superficial

examination

ing acutely,

with a history

Costa1 margin,

onset,

three

was aImost boardIike,

be in the right upper quadrant mass. Lungs were normaI. the heart

days’

There

or evidence

morphonucIears

85 per cent.

the peritonea1

presented

in the wound.

was found perfectIy of the and

removed,

and there

After

getting

head

duodenum

murmur

of the

normal.

but both

feIt normal.

compIeteIy.

The fecaIiths

aIong to the descending ent

omentum

loop of transverse

with no palpable

pancreas

The

operative tion.”

diagnosis

The patient

appendix

had

abdomen,

not Iimited

tention.

Morphia

enemata

with pituitrin

after operation dark coIored, Temperature, started

“There tracing

is very The

sedatives

slight

is characteristic

was Iit.tIe change

94;

in so far as possible. wound

cIosed.

impactions

with

intestinal

point,

accompanied

The adherThe

post-

obstrucpain in the disand

repiration

The second clay

a gastric Iavage was returned not typicaIIy

feca1.

evening

heart

28. That

of the correct

folIo\ving morning,

five days

the

diagnosis. after

the

as foIIows:

depression

in the general

of this,

and passed

gave Iittle or no reIief of pain,

of RTI,

are not inverted of an

were felt

by marked

persisted;

the

was reported

T waves

pIacques

and the

which gave the first intimation made

feca1 boIi.

the significance

and with a fou1 odor, though

puIse

An electrocardiograph, onset of the attack,

hard scIerotic

IittIe or no relief of the distention.

biIe stained, 98.4”~.;

numerous

to have very severe and constant

the same conditions

hbriIIating,

and STs.

“feca1

to any definite

and other

previously

the McBurney-

up with some difficulty,

were freed,

was then

in it

indurated;

been

beneath

We overIooked

coIon and sigmoid,

continued

colon,

stones

was slightly

adhesions

rather

aorta.

were broken

and cecum

poly-

with immediatety.

The Ieft kidney was larger than the right,

Numerous

in the waI1 of the abdomina1

puIse

13,600;

\vith \.er?; Iarge hard fecal boli,

scar; the cecum was quite bound down and contained was normaI.

103.2’~.;

it out of the way, the gal1 bladder

were a few omentar

The smaII intestine

at the base of

but with no cardiac

was proceeded

a redundant

seemed to

of an indefinite

Temperature,

in appearance,

The

tenderness

admissions)

fIexure, packed

norma

ducts.

stomach

Operation

under the

if any let up.

125/80; white blood count,

cavity

in the region of the hepatic

IittIe

but the greatest

of decompensation.

22; brood pressure

On opening

duration,

was a long systolic

IOO; respiration

hasty,

thin, oId looking man, suffer-

where there was a suggestion

(this had been noted on previous

enlargement

or any

ia the ether room. A rather

a moderateIv

of severe pain in the upper abdomen

of sudden

The abdomen

there,

revealed

infarction, condition

and marked

eIevation

of ST:{

in lead 3 or Iead 2 as yet. possibIy

stiI1 active.”

of the patient

throughout

This There that

632

J. M. T. FINNEY,

JR., AND

CHARLES

F. MOHR

day, and the foIIowing morning he died rather suddenIy, of a rapid cardiac faiIure with puImonary edema. During the entire postoperative course of three and one-haIf days, the abdomina1 distention couId not be reIieved, and the patient suffered excruciating pain in the abdomen, but never in the chest. At autopsy the pericardia1 sac contained hemorrhagic cIoudy Auid. The heart was moderateIy enIarged. The IateraI border of the Ieft ventricle was covered with patchy fibrinous exudate. The waI1 of the Ieft ventricIe showed a sharpIy defined margin separating an acute myocarditis from a reIativeIy norma myocardium. This area was typica of a recent infarct. In the Ieft coronary artery about I cm. dista1 to the bifurcation of the anterior descending branch, there was a compIete obhteration of the Ieft coronary and the beginning of infarction. Both coronaries were fuI1 of arteriosclerotic pIacques and segments of definite constriction of the lumen of the vesseIs. The abdomen was negative except for marked distention of the bowe1 everywhere, but without evidence of any type of organic obstruction. Otherwise the autopsy findings were entireIy negative. In this case we certainly did the patient no good by operation.

A few months Iater, when a very exceIIent medica man caIIed us in to see an acute gaII-bIadder attack in a man who had been a patient of his for severa years, this Iast experience was fresh enough in our mind to make us a Iittle suspicious, inasmuch as the picture did not seem to be aItogether typica1. In spite of some pressure brought to bear for immediate operation, we heId off. His story, in brief, was this: Six days before admission to the hospita1, which Iatter was when we first saw him, he began with a sore throat. At that time the temperature was IO~.O'F.; bIood pressure 128/8g. Examination was negative except for red fauces, a few &es at both bases, and some tenderness in the right hypochondrium. This picture showed Iittle change unti1 the morning of admission when the patient had a sharp attack of pain in epigastrium, with no radiation. There had been sIight dyspnea since the onset of the present iIIness; this morning there was also a IittIe orthopnea. There was no precordia1 pain, or pain in the chest; no jaundice, cIay coIored, or dark stooIs. Frequent sour eructations of gas occurred. PhysicaI examination reveaIed a heavy set man of fifty-nine years. The throat was now only sIightIy red. Respirations were somewhat rapid, 32, reguIar, rather shaIIow, aImost whoIIy costa1. Numerous fine and medium &es were noted at both bases. AI1 heart sounds were distant; no murmurs; apex impuIse not paIpabIe. To percussion the outIine was normaI. The puIse was regular, rather soft, rate 120; bIood pressure 120/88. AbdominaI muscIes were heId rigidIy.

CORONARY

OCCLUSION

AND

The Iiver edge was apparentIy on the right,

and sIightIy

beIow the xyphoid Soon after

with pulse running

tainabIe,

rate

some

admission

tenderness

about

100.2'F.; respiration

tion, but without

beIow

conscious

effusions,

and ascites.

at times.

The

chest

hours,

The

heart

enough

PericardiaI was tapped

blood pressure

The

until unob-

during

this time

and whiIe quite dyspneic,

sounds

were bareIy

audibIe,

times,

attacks

were Iow enough

of appendicea1

origin.

temperature

the second;

but none

of these

instance,

patient

except

have

rigidity

in the right Iower quadrant

for

to raise

the first, the

bvithin a few hours of the

has shown a moderate

rise. The

pain,

Most

and muscuIar

has the pain been referred attack

IOOO cc.

and 1600 C.C.

a11 toId, about three months.

showed a drop of 25 to 40 points

onset of pain. In no attack

rubs could be heard

of abdominal

tenderness

In every

picked

and pleura1

and the first time

to the hospita1.

with marked

graduaIIy

edema, with pericardia1

and pleura1 friction three

his return

down the Ieft arm. Every and moderate

persisted.

aIthough

1300 C.C. straw coIored

to warrant

been in the epigastrium, the question

The pain rapidly

dropped

The bIood pressure

genera1 dependent

he has had severa

awhiIe. Two attacks

of dyspnea,

140. Temperature ranged from g&o” to from 28 to 40. There was marked abdominal disten-

straw colored the third. He was in the hospital, severe

attacks

xyphoid

rapidIy

was just

was more relaxed.

120 to

bIoody fluid were removed; discharge

tenderness

reguIar.

and oriented,

pain or tenderness.

up, and he deveIoped

Since

marked the

633

beIow the costal margin

marked

his bIood pressure

of no pain whatever.

apparentIy

EMERGENCY

The Iower abdomen

for thirty-six

was perfectly

compIained

most

he began to have rather

and so remained

the patient

The

up to 140 or ISO, but perfectIy

though

third night after

two finger breadths

tender.

in the midIine.

admission

disappeared,

ABDOMINAL

to the precordium

or

to high Ieucocytosis,

is at present

asemi-invaIid,

but abIe to be at his office at times.

The GmiIarity of recurring galI-bIadder attacks to angina1 seizures has been recognized for some time, together with the difficulty, frequentIy, of differentiating between them. This problem is further compIicated by the now fairIy weII-estabIished connection between chronic galI-bIadder disease and myocardia1 damage. We feeI, however, that not nearIy enough emphasis is pIaced upon the abiIity of a pureIy cardiac lesion to simuIate an acute abdomina1 emergency so cIoseIy as to make it aImost, if not entireIy, impossibIe accurateIy to distinguish between them. It certainIy is not necessary to point out to a group such as this, the danger and disastrous resuIts

634

J. M. T. FINNEY,

JR., AND

CHARLES

F. MOHR

of N-advised operation due to a fauIty differentiation between these conditions. It is for the purpose of again caIIing attention to this diffIcuIt problem of diagnosis, that we present this paper. We fee1 that it may not be iII-timed or amiss, inasmuch as the Insurance companies are reportmg a tremendous increase in the incrdence of coronary accidents during the past two years. In a review of some forty odd articIes in the Iiterature, contributions by Barnes, Brown, HaIsted and Bauer, and FauIkner, MarbIe, and White seem particuIarIy pertinent. The Iast named is especiaIIy so, in that it tabuIates the points of differentia1 diagnosis in 30 cases of coronary occIusion and 30 cases of choIecystitis; we draw extensiveIy upon it. We wiI1 attempt no further reference to or summarization of the Iiterature in the short time at our disposa1. SimiIarIy in the matter of referred pain, whiIe a great dea1 of work has been done, and much written, deaIing with the subject from anatbmica1, experimenta1, and theoretica standpoints, we can not, for obvious reasons, not the Ieast of which is our own ignorance of the subject, enter into any discussion at a time such as this. Suffice it to say that fibers of the vagus and sympathetic system suppIy both the heart and upper abdomen, and that they exit from the spina cord within one to four segments of each other. In an effort to determine whether the site of the coronary occIusion pIayed any part in the reference of the pain to the abdomen, we were able to pick out 5 case records at the Johns Hopkins HospitaI, and two at the Union MemoriaI HospitaI, a11from patients in whom the pain had been pureIy abdomina1, and in whom subsequent autopsy reveaIed definite myocardia1 infarction and negative upper abdomina1 findings. Five of these had infarcts in the anterior waI1 or apex of the Ieft ventricIe, 4 from occIusion of the anterior descending branch of the Ieft coronary, and one from occIusion of the circumflex branch of the Ieft coronary; 2 had infarcts in the posterior waII of the Ieft ventricIe with occIusion of the right coronary

CORONARY

OCCLUSION

AND

ABDOMINAL

EMERGENC17

635

artery. In 2 other cases which did not come to autopsy, the eIectrocardiagraphic interpretation in one was occIusion of the right coronary artery; in the other, the Ieft. From this it wouId seem that neither the artery occIuded nor the site of that occIusion has any controIIing influence over the occurrence of abdomina1 pain in coronary accidents. In 5 of these cases, eIectrocardiograms showed characteristic changes of the RT segments and the T waves. It must be borne in mind, however, that the diagnostic vaIue of the eIectrocardiogram is comparativeIy sIight when the tracing is made shortIy after the onset of the attack, and that a certain amount of time, often as much as severa days, must eiapse before the typica curve is obtained. In one of our cases this fact is so we11 iIIustrated that we wiI1 quote the reports of four successive tracings. The first was made on the third da;\- after onset of symptoms. “Norma1 Sinus rhythm. Changes in the RS T segment indicate myocardial disease and, whiIc not pathognomonic, are entireIy compatibIe with a recent coronar)~ occIusion.” Three days Iater we are toId, “Tht changes which have occurred in the RS T segment since the previous record are strong evidence in favor of a recent myocardia1 infarction. Record is of the T1 type.” Then after four more days, ten days from the time of onset: “Th e record is fairI\- characteristic of the T, type seen after thrombosis of the anterior descending branch of the Ieft coronary artery, with infarction of tht anterior apica portion of the Ieft ventricIe.” FinaIIy, one week Iater, “Since the previous tracing there has been a sIight shift of the RS T segment toward a norma appearance. The coronary T waves are conspicuous and the notching of the QRS in Lead I suggests myocardia1 damage.” Like “ IaboratorJmethods of precision” in a good many other instances, the eIectrocardiogram furnishes vaIuabIe confirmatory evidence at times, but can not be depended upon soIeI)- for a diagnosis, particuIarIy in the earIy stages of the disease when its recognition is most important, and differentiation most perpIexing.

636

J. M. T. FINNEY,

JR., AND

CHARLES

F. MOHR

Another sign which we might expect to be a reaI diagnostic aid, and which we usuaIIy associate with a coronary thrombosis, is a sudden, marked faI1 in the bIood pressure. This, however, is not nearIy so heIpfu1 as one might imagine at first thought. Many patients in whom we are caIIed upon to make the diagnosis, are seen for the first time after the onset of the acute symptoms. Therefore we have no way of knowing what their bIood pressure normaIIy registers, for comparison with the reading which we may obtain at that time-witness our first case referred to. ConsequentIy, unIess there is a markedIy abnormaIIy Iow pressure, there would be no reason to have our suspicions aroused on that score. And further, there is a group of cases in which there is no appreciabIe initia1 drop, for exampIe, the second and third cases which we cited, even though we are in possession of a base Iine for comparison with the present reading. The doctrine that coronary occIusion is aIways accompanied by an immediate drop in bIood pressure is far from true; the drop is often noted onIy after severa hours or even days, and sometimes does not occur at aI1. When noted, it is a great aid in the correct diagnosis; when absent, it may be onIy misIeading. Upon what are we going to base our diagnosis, then, for we must have something to work on immediateIy, whiIe trying to decide whether this particuIar case is a surgica1 emergency, warranting immediate operation? If it is a perforated uIcer, either gastric or duodena1, it aImost sureIy demands such urgency; if a ruptured gaI1 bIadder, or one with associated acute pancreatitis, speedy intervention is just as necessary; and even in the event of a simpIe acute gaII-bIadder attack, the trend is more and more toward appIying the same principIes as have Iong obtained when deaIing with the appendix, nameIy, prompt remova1. UnfortunateIy, so far as we can determine, there is no sure way of making the differentia1 diagnosis between any of the preceding conditions, and the comparativeIy rare case of coronary thrombosis with pureIy abdomina1 symptoms. But

CORONARY

OCCLUSION

AND

ABDOMINAL

EMERGENCY

637

there are certain considerations which may heIp toward a proper soIution of the diIemma. First, there are two genera1 factors which shouId be taken into account, age and sex. In the cases anaIyzed by FauIkner, MarbIe, and White, the average age of the gaII-bIadder group was forty-seven and two-tenths years, with extremes of twenty-three and sixtgfive years ; the average age of the coronary occIusion group was fifty-eight years, with extremes of forty-two and seventysix. Our own cases of the Iatter were a11 in the fifties, with an average of fifty-four and seven-tenths years. ApparentIy, at Ieast 63 per cent of coronary occIusions wiI1 occur after the fiftieth year, though the incidence in younger individuals does seem to be increasing. Now as to sex, gaII-bIadder disease is unquestionabIy more common in femaIes, some figures putting the ratio as high as four to one. On the other hand, coronary occIusion is much more frequent in maIes, the estimated ratio running as high as four and one-haIf to one. AI1 of our cases of the Iatter were maIes. Nest, a most essentia1 diagnostic aid is a very thorough and carefuIIy taken history, not onIy of the present iIIness, but, in minute detai1, the past history as weI1. Recognizing the fact that in many cases chronic gaII-hIadder disease may masquerade for years as miId angina, and vice versa, stiI1 it is not infrequentIy possibIe, by very carefu1 questioning, to get a definite Iead in the right direction. Has the discomfort been precordia1; has there been a feeIing of construction of the chest; has it been associated with any form of activity; has there been any dyspnea; have there been any abnorma1 sensations associated with the heart beat, such as tachycardia or irreguIarity? On the other hand, has there been indigestion characterized by eructations and AatuIency ; was the discomfort reIated to the ingestion of food, and if so, any particular kinds of food; have the attacks ever come on whiIe at rest, as when in bed at night; has there been any periodicity, as reIated to mea1 time, time of day, or season of year; have there been attacks of severe pain, other than the present one?

638

J. M. T. FINNEY,

JR., AND

CHARLES

F. MOHR

Affrrmative findings in the first group point toward cardiac origin, in the Iatter group, toward abdomina1. CertainIy the Ionger the history, and the more frequent, proIonged, and severe the attacks of discomfort or pain, the Iess apt is it to be cardiac in origin. However, one of our patients had been under observation and treatment for over seven years by an eminent gastroenteroIogist for chronic choIecystitis, which autopsy proved he did not have, though there were numerous smaI1 fibrotic scars scattered throughout the heart muscIe. FinaIIy, a cIose scrutiny and judicious evaIuation of the story and symptoms of the present attack, correIated with the physica and Iaboratory findings. The pain in coronary occIusion (we are referring, of course, onIy to that smaI1 group with abdomina1 symptoms) may be absoIuteIy IocaIized in the gaIIbladder region, more rareiy Iower down in the right Iower quadrant, but most frequentIy possibIy in the mid-epigastrium, nearIy in the midIine beIow the xyphoid. It rareIy, if ever, radiates through to the back, as the pain of a distended gaI1 bIadder tends to do. The point of maximum tenderness on pressure is aIso apt to be more nearIy in the midline than with an acute gaII-bIadder attack. This may be in Iine with the sudden enIargement of the Iiver seen in the rare cases of infarction of the right side of the heart, and be dependent upon stretching of the capsuIe of the Iiver, as we11 as referred cardiac pain. AIso, whiIe we are considering the Iiver, aIthough jaundice is not a common finding in coronary occIusion, there have been a number of cases reported, the jaundice, in some instances, having been quite marked, so that its presence, whiIe suggestive, is not in any way pathognomonic of gaILbladder disease. Dyspnea, paIpitation, or the sensation of irreguIarity of heart rhythm is much more common with coronary occIusion, though it may occur in other conditions, Signs of cardiac faiIure such as cyanosis, weakened heart sounds, rbles at the Iung bases, and sudden drop in bIood pressure, are obviousIy in favor of coronary occIusion, but are often rather Iate manifestations. StiII, even these may be associated with the

CORONARY

OCCLUSION

AND

ABDOhIINAL

EMERGENCI’

639

shock seen in acute pancreatitis. A precordia1 friction rub is pathognomonic, but can be heard in a reIativeIy smaI1 percentage of cases, and then usuaIIy Iate. The temperature and puIse rate seem to have a tendency to be sIightIy higher in coronary occIusion, as is aIso the case I\-ith the n-hite bIood count. As has aIready been mentioned, any help from eIectrocardiography is apt to be too Iate to be of use in making the immediate diagnosis, but shouId bc utiIized, if avaiIabIe. It wiI1 eventuaIIy show changes characteristic of cardiac infarction in probabIy 90 per cent of cases. In summary and concIusion, we present in this paper no new disease or diagnostic principIe, but mereIy caII your attention anew to a pseudo-surgica1 emergency which can offer as nice a probIem in differentia1 diagnosis, for the exercise of sound judgment, as may ever face an>- of us. REFERENCES I. BROWN, T. R. Cardiac symptoms in uncxpectrd gall bladder disease. Libman An&. vol.,pp. 265-271, 1932. 2. HALSTEAD, J. A., and BAUER, W. Jmmdix in coronary occlusion.Med. C/in. N. America, pp. 95 1-60 (Jan.j 1933. 3. FAULKNER, J. M., MARBLE, H. C., and WHITE, P. D. The DifferentiaI Diagnosis of Coronary OccIusion and ChoIelithiasis. J. A. M. A., pp. 2028-2082 (Dec. 27) 1924. 4. BARNES, A. R. MedicaI and surgical probtems associated with coronary sclerosis. PrOC. .%UtffVkW. k&f0 Ckn., pp. 290-291, '931. 5. BARNES, A. R. and WHITTEN, M. S. Study of the RT interval in myocardial infarction. Am. Heart J., pp. 142-169, Ig2g. 6. BARNES, A. R. The incidence and situation of myocardia1 infarction in IOOOconsecutive postmortem examinations. hoc. .%a$ Meet. Mayo Clin., pp. 367-369, 1930.

DISClJSSION

ON PAPERS

OF DRS. BUNCH AND MOHR

AND

FINNEY,

JR.

DR. NATHAN WINSLON-,BaItimore, hlcl.: We fee1 that many of these cases are being overIooked by the profession. CertainIy it wouId seem so when members on the staff of the University of Maryland have operated on 15 cases during the past ten years. Of these 15, 9 patients, or 60 per cent, recovered. ShipIey and I have reported IO of these cases in detail.* Six, or 60 per cent, of the patients in this group reco\.ered, so there seems to be * Arch. Surg., (Sept.) 1927.

640

J. M. T. FINNEY,

JR., AND

CHARLES

F. MOHR

no improvement, as yet, in the operative resuIts. As none of these patients wouId have Iived, we fee1 that a saIvage of a IittIe more than 50 per cent of them ampIy demonstrates the advantages of the operative over other kinds of treatment for pyopericardium. PuruIent pericarditis is an abscess and, Iike any other abscess shouId be treated by incision and drainage. Too much cannot be said in favor of earIy operation, but Iate operation shouId not be denied these patients. The best approach is the costoxiphoid route with resection of the Ieft fifth, sixth and seventh costal cartiIages, and, if more room be needed, a piece of the adjoining sternum may aIso be removed. There are three chief factors which govern the prognosis: (I) the time of the operation; (2) the type of the organism, and (3) the original condition of which the pyopericardium is a CompIication. Obviously, suppurative processes in other parts of the body, unIess detected earIy and promptIy remedied, render the prognosis Iess favorabIe. Most of these patients (80 per cent) are under thirty years of age; 70 per cent are males and 30 per cent femaIes. Diagnostic aspiration is rarely indicated. The diagnosis shouId be made on the cIinica1 signs and the characteristic x-ray shadow. When the pericardium contains fluid, the heart is usuaIIy found Iying against the anterior waI1 of the sac. This may give a misIeading nearness and cIearness to the cardiac sounds. TroubIesome postoperative adhesive pericarditis does not occur as often as is generaIIy supposed. Dr. Bunch has done a rea1 service by caIIing attention to these cases, for wherever pneumonia is prevalent, there aIso are to be encountered, at times, patients suffering with puruIent pericarditis. DR. GOODRICHB. RHODES, New York, N. Y.: In the beginning of this Iesion the pus is Iocalized in two pockets before the whole of the pericardium is MIed. One of these is in the aortic region and the other is above the diaphragm. Both of these pockets are posterior to the heart. This earIy formation of pus can be diagnosed by x-ray and can easiIy be misinterpreted as a diIatation or an aneurysm of the aorta. As a result of the posterior Iocation of the pus formation the heart is pushed forward against the chest wal1 by the increasing exudate. I have studied reports of I 18 operated cases, and in a11 cases in which the position of the heart was stated it was found to be anterior. This I consider a very important finding, for in at Ieast 2 reported cases the heart has been punctured with fata resuIts through ignorance of this pathoIogica1 anatomy. Second: the anatomy of the pericardia1 reflection of the pleura and its reIationship to the sternum is very vague in a11 our anatomica textbooks. And for a very good reason. It is very indefinite and varies within very wide limits. In order to study this at first hand I requested the dissecting room students to make sketches of these relationships in a11 the bodies.

CORONARY These

OCCLUSION

showed

me, that

such

case, causing

case

of the

location

that

the pIeura.

pleura,

case has been cured by repeated it is unnecessary.

recovered

The

disturbance

nized by interna

medica

to us the better rate

servativeIy

approaches

in

I have

left

second

pericarditis

upon

cavity

are turned

over

has pointed

out that the

pericarditis

treated

con-

the

ReIativeIy

pericarditis, number

abscesses

treatment

drain-

few patients if the

with

pericardium

of them

is

will die from

in the liver, spleen, kidneys,

therefore

are actuaIIy

better

wouId seem to indicate. 4 patients

with

suppurative

The lirst patient The

pericarditis.

patient

was Iater

pericarditis,

had an empyema

suppurative

drained. which

patient

The pericardium

deveIoped

drained.

with

of the right

an empyema

He eventuaIIy

of

made

a

and

admission

a white

dista1

treated.

after

the

as soon

was

of the

He apparently When

operated

upon

to the hospita1. became

was drained.

chiId twenty

phaIanx

pericarditis.

one week, then containing

hours

was drained

patient,

of the

suppurative

osteomyelitis

She deveIoped

of the evidence

and

a

onset

as the

femur

of suppurative

of the

osteomyelitis

diagnosis

was

made.

made a good recovery.

third

acIequateIy

an acute

septicemia.

forty-eight

pericardium

myeiitis

had

aureus

She eventually

dium

operative

statistics

about

the

sick

has

recovery.

The

The

recover.

as for exampIe,

and then

Staphylococcus and

cent

with an associated

pIeura1

compIete

physica

medicaIIy

The sooner this is recog-

Dr. Bunch

a considerabIe

and 2 deaths.

was aspirated the

but

operated

pleural cavity

by the

No case treated

suppurative

die from

from

than the mortality

Va.:

with

30 per

resuIts

2 recoveries

and as a diagnostic

men and the earIier the patients

pericarditis conditions,

The

No

IOO per cent, whereas in those given adequate

drained,

associated etc.

to paracentesis.

can be made

a surgica1 disease.

patients

approximateIy

adequateIy

in one

of the patient.

of the heart and the uncer-

aspirations,

diagnosis

DR. I. A. BIGGER, Richmond,

suppurative

the death

wiI1 be the resuIts.

mortality age

upon

pericardium

I have seen this happen

and x-ray.

and this is distinctIy

641

is forced

into the

I am opposed

measure

circuIatory

conclusion

the forward position

of the

EMERGENCY

a needIe

which determined

reported signs,

the

can we insert

of not entering an empyema,

For these two reasons: tainty

ABDOMINAL

wide variations

in no given

and be certain

AND

months

Ieft

ring

developed

First examined under

IocaI

of age, had an osteo-

linger,

which

a septicemia

was

and

not

then

a

this chiId was desperately

anesthesia

He showed considerable

a short

improvement

time

after

for about

worse, and died about two weeks after the pericar-

Autopsy

showed

no actua1 pus. There

the

pericardium

were StaphyIococcus

the lungs, Iiver, and spleen, which had obviousIy

to be quite aureus

clean,

abscesses

caused the patient’s

in

death.

642

J. M. T. FINNEY,

JR., AND

CHARLES

F. MOHR

The fourth patient, a white boy fourteen years of age, had a totaI pneumonectomy done for a carcinoma of the Ieft lower Iobe bronchus. He had an empyema at the time of the pneumonectomy and a few days Iater deveIoped evidence of suppurative pericarditis. He was operated upon and the pericardium drained, with a resuhing marked improvement in his general condition for about one week. He then deveIoped enIargement of the Iiver, ascites, and edema of the trunk from the costal margin down and of the Iower extremities. The pericardium was markedIy thickened, so the anterior portion of it was excised and the posterior portion of the pericardia1 sac expIored for saccuIated IIuid but none was found. He seemed to show temporary improvement from this procedure but after a few days he became rapidIy worse and died. Autopsy reveaIed a marked constriction of the inferior vena cava at the point of its entrance into the pericardiat sac. There was aIso a septic hemorrhagic infarction with bronchia pneumonia in the right lung. DR. JOSEPHA. DANNA, New OrIeans, La.: Most of the deaths in suppurative pericarditis are due to associated conditions, or to the origina condition to which the pericarditis is secondary. Since a suppurative pericarditis presents the same conditions as those found in empyema, both conditions it seems to me shouId respond to the same treatment. These patients are very sick and the Iess we do to them the better they stand it. I shouId Iike to suggest, therefore, their treatment by aspiration and air replacement which has given me and many others who have used it such good resuIts in the treatment of empyema. There are three reasons why I think it shouId be better than open drainage. One is that it causes Iess shock and Iess trauma to the patient. Second, if you empty the pericardia1 cavity entireIy of IIuid, the pericardium wiI1 have an opportunity during the two or three weeks it wouId take the air to be absorbed to resume to a great extent its normaI state once more and the formation of adhesions wouId be minimized. There is another important reason and that is this, that with a heart surrounded by air an x-ray picture wiI1 show very clearly whether there is additional abscess formation, and the patients who wouId otherwise die because an additional pocket of pus is undiscovered and undiagnosed wiII be caught and this pocket can be drained. DR. FRANK P. STRICKLER,Louisvihe, Ky. : I wish to call attention to the bIood pressure in coronary occlusion. We know that coronary occlusion occurs from fifty to sixty years of age. We know that the bIood pressure drops materiahy in these cases, aIso in shock. In cases of shock there has been no damage done to the heart muscIes, and the bIood pressure wiI1 rise when shock treatment is instituted.

CORONARY

OCCLUSION

AND ABDOMINAL

ERIERGENCY

643

In the cases of coronary occIusion the heart muscies and vesseIs themseIves have been damaged. This is foIIowed by a drop in the bIood pressure, then a graduaI rise to around IOO mm. Hg and the bIood pressure remains stationary at this point. I have seen severa cases of coronary occlusion which had a surgicaI aspect, and have discussed this subject with some of my heart speciaIist friends, and they appear to be of the same opinion as myself. I fee1 if one wiI1 carefuIIy watch the bIood pressure readings, one wiI1 get an earIier line on these patients than we can hope to get with eIectrocardiograph tracings. I think that most any welI-trained doctor can take bIood pressure readings with a reasonable degree of accuracy, and thereby make a much earIier diagnosis. DR. K. H. AYNESWORTH, Waco, Texas: I wish to discuss the feature of pain in connection with Dr. Finney’s paper. In 1914 a patient was brought in with symptoms of an acute emergency. I operated and found the viscera perfectly normaI, which was a great shock to me. After operation I studied the patient as I shouId have studied him before operation. It was an angina1 pain and I did not understand coronary occIusion then as I do now. I found the gaI1 bIadder normal, but I had to do something. Fearing that it might be gaII-bladder pain, a drainage tube was put in the gaII bladder. Soon afterward- I had a letter from a doctor in another town asking for my records and saying they wished to operate. I teIegraphec1 him not to operate for it was a heart condition. That was twenty years ago. From the internists 1 have not had the heIp that I wanted, but if we take the cIinica1 signs the pain is of the same kind that often occurs in acute upper abcIomina1 conditions. The pain is splanchnic, which is diffuse. It is not, in my experience, paroxysmal. We know that, embryoIogicaIIy, the heart is suppIied with the same nerves as the intestines. The vagus suppIies the heart and the small intestines; aIso, we know there is a spIanchnic sympathetic nervous connection to both the heart and the gastrointestinal tract down to the Iarge bowel and in these structures the pain is always diffuse. It may be in the hypochondrium or in the hypogastrium or anywhere, but it is diffuse and more or Iess paroxysmal, but in the heart it is unlikely that we wiI1 have the same type of pain as in the intestine. The nerves in the heart go to the gangIia of the centra1 nervous system and connect with the motor nerves that go to the chest waI1. That is why vve have a sense of compression in the chest and the pain is very diffuse; it may be felt in the chest, in the neck and in the upper abdomen. It is characterized by more or Iess continuous pain in the heart and gives the symptom of excruciating pain in the chest which is never present in galIbladder difficuIties.

644

J. M. T. FINNEY,

JR.,

AND

CHARLES

F. MOHR

Dr. Finney spoke of tenderness. In my experience there is no tenderness in the abdomina1 wall and that is one of the characteristic symptoms of earIy coronary pain. The abscess of tenderness IocaIIy in the epigastrium is characteristic of heart pain and is just the opposite condition found in any pain due to perforation of the gaI1 bIadder, the stomach, or exudate in the abdomina1 cavity. On these symptoms alone, a continuous type of pain, the diffuse type of pain, and the absence of tenderness, the diagnosis of coronary pain can be made. In my experience the pain has been so diffuse that it couId not be due to inAammatory Iesions. Another thing is that the patient is not quiet, as in abdomina1 conditions, but very restIess. DR. ROY D. MCCLURE, Detroit, Mich.: Many cases of thrombosis and embolism, especiahy of the coronary vessels, can be avoided. From persona1 experience we know that an attack often starts after strenuous exercise, and I never miss an opportunity of preaching to my friends that they shouId not take needIessIy strenuous exercise after the age of forty, when so many deveIop coronary troubIe. I fee1 that in the treatment a certain amount of quietness is necessary, but it is very nice to have the confidence of the patients and make them fee1 that they have a chance for recovery after they have given up hope. DR. RUDOLPH MATAS, New Orleans, La.: Dr. Finney has done we11 to direct attention to a pitfaIl in diagnosis which is easy to faI1 into when patients are brought to an emergency clinic in a state of shock or coIIapse with no adequate history, with signs and symptoms pointing to an acute perforative or occIusive abdomina1 Iesion which calIs for immediate expIoration. It is onIy after the negative resuIts of the expIoration or the reveIations of a postmortem brings to Iight the rea1 seat of the Iesion in the heart, that we realize how cIoseIy and deceptiveIy an atypical angina of the ceIiac type can simuIate an acute subdiaphragmatic Iesion. On the other hand, the error may be reversed when unexpected fataIities, occurring in the course of abdomina1 disease, and especiaIIy after operations for acute abdomina1 Iesions, are attributed to heart faiIure. Now that we know so much more about coronary disease and thrombosis than formerIy, the tendency is to transfer the responsibiIity for sudden postoperative deaths from the abdomen to the heart. Though this may be correct in most cases, the diagnosis of death by coronary thrombosis is often an assumption which, when not verified by necropsy, is subject to abuse as a convenient cover for postoperative compIications that Iie beIow the diaphragm. The number of cases of puruIent pericarditis which Dr. Bunch has been caIIed upon to operate is much Iarger than that which faIIs to the lot of most surgeons. Though the reported cases of tapping or paracentesis of the pericardium are numerous enough in the Iiteratcre, the cases of peri-

CORONARY

OCCLUSION

cardiotomy

for puruIent

aIIy stand

out prominently

AND

or other effusions

exceed,

HospitaI

a11 toId,

Two

of these

these

including

patients

a pericardiotomy

because

tion. The comparative Charity 1930,

HospitaI. to JuIy

diagnosed hospital,

I,

period,

that

amount

show no pericardiotomies hvere aspirated,

this incidence shown

223,657

entireIy

2

deaths,

underestimates

by the fact that

to

to the classified

admissions.

7300

for the same period

for acute

pericarditis.

Three

none of which

were puruIent.

the frequency

of pericarditis that

come to autopsy

or reIics of some past

or oId pericarditis.

It is surprising,

however,

despite

cadaveric

deveIop

puruIent

this

frequent

pericarditis

are

records for the time mentioned

of a11 bodies

That is well

show evidence that

4-7 per cent

as acute

were admitted

records

I,

were so

of the cases specificaIIy

the surgical

of the

from January

25 were cIassified

patients

or open operations

with

serum.

accumula-

of pericarditis

to about one case of pericarditis is that

of the

is shown in the statistics 30 cases

the

I had to transform

or seropuruIent

and of these,

period

is more significant

cases

only

wound.

but one of of these,

appearance

of this institution

which would make the incidence

as pericarditis, What

show that

that

During

of pericarditis

for peri-

by heart One

which

bIoody

for puruIent

annua1 reports

1934,

during

pericarditis.

rarity

The

does not

recoveries,

endocarditis.

aspiration

of the

AI1 the rest were pericardiotomies

caused

operative

a coincident

first case, in 1886, was an attempted into

institutions

I have been caIIed to operate

one hemopericardium

from

rare, and usu-

in the surgica1 service

and other

died and 3 made

died uItimateIy

645

when they are performed.

in over fifty years

of New OrIeans

3 cases in which

cardia1 effusions,

EMERGENCY

are comparativeIy

in hospita1 statistics

My own persona1 experience of the Charity

ABDOMINAL

reIativeIy

and these were only recognized

as terminal

compIications

from \rarious sources a11 to

10s reported

cent

a mortality

in 1 termina1

covering

reported

cases of acute pericarditis or terminal pyococca1 often

anc1 rheumatic

die before

overwhelming logic

cases). in the

that

that

HospitaI

There

The

I once compiled

Igoo to 1927 amounted

exceeding

without

a11 occurring

pneumonic.

which

43 per cent.

Hospital

surgical

just

can be no question

in The

mentioned,

intervention

pneumonic, Even

influenzaI,

(100

that

per

many

have

In the struggIe

the patients so

much

streptococcal,

when recognized,

has had time to develop

compression.

genera1 infection,

examinations

from

at the Charity

infections.

the effusion heart

cases

are overTooked when they appear as intercurrent

compIications

distentionyand

the period

of 30 per cent

chiefly

effusions

\vith a mortality

puruIent

the

Charity

as such at autopsy,

infections,

for purulent

cases

30 cases of pericarditis yielded

of genera1

of pericardiotomy

fe\v. The

show that there were just 4 cases of purulent

pericarditis, statistics

incidence,

signs of pericardial for survival

are scarcely

simplified

the patients

the

from an

fit for the radiodiagnosis

of the

646

J. M. T. FINNEY,

JR.,

AND CHARLES

F. MOHR

effusions. When they do survive with a residual pericardia1 accumuIation, whether puruIent or otherwise, the patients are left so weak and exhausted that an operation, which might be relatil-ely simple and safe under other circumstances, becomes one of grave consequence. When the diagnosis of a pericarditis with effusion, whether serous or puruIent, is established, the procedure to be adopted for its evacuation and permanent cure presents itseIf as a worrisome problem. Is it pus or steriIe serum that we are deaIing with? is the first question. To decide this question, a preIiminary expIoration is necessary. Under these circumstances, the temptation to tap or puncture the pericardia1 sac with a trocar or aspirating needle is very great, but the risk of wounding the heart and of infecting the pIeura is no idIe fear, and we hesitate. The history of paracentesis pericardii when spread over the chest and precordium is like a map pIotted with the historic names of the innumerable surgeons who have sought spots where a needle or trocar couId be thrust into the pericardium without fear of injuring the great vesseIs, the pleura, and the heart itself. The great number and variety of these so-caIIed points of eIection is the best proof of their faIIibiIity and unreliability. The “triangle of safety” which the Russian surgeon Voinitsch described so accurately nearIy forty years ago, in the left Iowest chondrosterna1 angIe, is the nearest approach to the pericardium in a pIeura-free mediastina1 space. Despite the fact, as Dr. Rhodes has remarked and I have confirmed by numerous dissections, that even this space is often overIapped and encroached upon by the Ieft pIeura, it is undoubtedly the best area to work in when pIeura1 compIications are to be avoided. The chief danger of paracentesis Iies, not so much in the pIeura, as in the IiabiIity to puncture or penetrate the thin right ventricIe which, in Iarge effusions, is pushed forward against the anterior pericardial waI1, where it Iies directIy in the path of the needIe. WhiIe hundreds of pericardia1 punctures have been made without accident, this danger is rea1, as attested by numerous instances in which the heart itseIf has been tapped or the coronary vessels injured. In view of the uncertainties that attend expIoratory punctures, I have in a11 my cases perferred to expose the pericardium by open dissection carried through an obIique line along the Ieft edge of the sternum and base of the xyphoid cartiIage, resecting as much of the sixth or seventh Costa1 cartiIages at the sterna1 juncture as wouId permit digita paIpation and exposure of the sac. A smaI1 incision is then made between forceps. In puruIent cases, the incision is enIarged and the edges of the pericardium are sutured to the inverted skin or fascia, thus converting the operation into a pericardiostomy. In a11 cases, a soft catheter or the bulbous tip of a long suction apparatus is introduced into the posterior recesses of the pericardia1 sac where the buIk of the fluid usuaIIy accumuIates in greatest quantity.

COROKARY

In a11 my operations anesthetic

sedation

There

I avaiIed

after-treatment

and

required

in specia1 cases,

cIinica1 and postmortem and to emphasize cardiotomies have

been

the

fully

as pericardia1

evidence

methods

in my previous

and I can very

which

the

Iabors,

heart.

This patient fever.

diagnosis

if the

fewer cases

as was shown clinician

of purulent

bIood

had

been

by the needIe

The

use of the

point

Dr.

the tenderness,

as acute

tenderness

intra-abdomina1 tion there, tenderness

maintained

for in several with muscular

lesion. I thinkthere

StrickIer

* In r&sing add did the gist

makes

then the rise, and then maintenance

over

But it does not always hold was exactly

a period

cases

the mean of the

of twelve

I have seen there

rigidity is another

years

and

a IittIe

has been just

as one would get with a true possible means of differentia-

and that is that the point of tenderness in ruptured

in

and fewer

is quite cIear and a rea1 heIp if we know we frequentIy get was; unfortunateIy

pressure

in the midline under the xyphoid

count

needIe

eighteen hospital admissions. I thank Dr. Aynesworth for what he said, but have to disagree about

under

congenita1

a high Ieucocyte the

wiII be recognized

our first record only after the onset of trouble. that

for therapeutic

the d&cuIties

bronchitis,

true for in one of our cases the blood pressure pressure

or thera-

Lvhich in so far

in the Iast picture,

pericarditis

of IeveI not as high as the original origina

of open peri-

began as far back as the

is denied

about the initia1 drop in bIood pressure, the

publications,

in 1907.* I hold no brief

cases will be operated upon. DR. J. M. T. FINNEY, JR. (CZosing):

what

safety

we11 appreciate

had a Iarge shadow,

CertainIy,

of

of pericarditis

in my cases were a11 confirmed

I saw them,

and

of my

contradictions

of exploratory

are concerned,

before

internist

of are

the points at issue and details of technique

surgery

The diagnoses

to the

of the far greater

New OrIeans meeting of the Association DK. GEOKGE H. BUNCH (Closing): paracentesis.

that

the scope and purpose

attention

simpIe

Furthermore, discussed

questions

of technique

in regard to the incidence

my conviction

and cardiac

647

aided by pre-

controverted

modifications

to direct

over the so-called

peutic paracentesis.

of local anesthesia,

but this is beyond

is chiefly

EMERGENCY

etc.

could be said regarding

is much that

which

ABDOhIINAL

myseIf

with morphia,

drainage, discussion,

AND

OCCLUSION

is apt to be more nearly

than to the right where we get most of the

uIcers and acute

galI-bIadder

pathology.

the stenographer’s copy of this discussion I have taken the liberty to a number of facts and statements which I had prepared for the meeting, but which I not read because of the limited time at my command. With the kind permission of secrrtar?-. I have made these changes. which add to the mnttrr but do not alter the or purport of my original remarks;.