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Suppurative pericarditis
SUPPURATIVE DONALD
E. Ross,
M.D.,
PERICARDITIS
F.R.C.S.
(ENG.),
F.R.C.S.
(ED.),
F.A.C.S.
Ross-Loos MedicaI Group LOS ANGELES, CALIFORNIA
Introduction. Suppurative pericarditis is much more common than is ordinariIy thought. Most cases, however, are found
of the right auricIe. When aspiration is necessary, it is the writer’s beIief that the fifth interspace in the midcIavicuIar Iine
FIG. I. Shows the tremendous enIargement of the heart shadow. Note the unusual persistence of the pericardio-phrenic angle on the right side.
FIG. z. The cardiac shadow is much reduced in comparison with Figure I.
as a compIication to pneumonia, and are usuaIIy discovered at autopsy. Since cases cIinicaIIy diagnosed and successfuIIy treated are comparativeIy rare even yet, I presume to report this case. Another reason is to outIine and emphasize certain factors, and particuIarIy to recommend a surgica1 approach which, aIthough it is not new, has not generaIIy been adopted. Treatment of puruIent pericarditis is necessariIy surgica1. It is permissibIe to aspirate for diagnostic purposes and possibIy for paIIiative treatment. Technique of Aspiration. It may be noted that when the pericardium fiIIs with pus the heart “ fIoats” forward; therefore a needIe, when introduced, may easiIy enter the heart muscIe or may damage one of the coronary vessels. Aspiration is sometimes done to the right of the sternum and in this area the needIe might even tear the thin auricuIar waI1
is the safest. The needIe is directed upwards and sIightIy outwards to keep the point from approaching the heart itseIf. It is quite obvious that this method couId not possibIy drain adequateIy the posterior part of the pericardium, known as the obIique sinus. Dijkulties of Draining the Pericardium. Drainage of the pericardium usuaIIy is accompIished by resecting a portion of the Costa1 cartiIages of the fourth or fifth ribs near the sternum, opening the pericardium and inserting a rubber tube or Penrose drain. This obviousIy gives ineficient drainage, since adhesions form readiIy and, as pointed out above, the heart rides forward against the anterior pericardia1 waI1. It is rather a far cry to the Iarge dependent sac behind the heart caIIed the obIique sinus, which is difficuIt or impossibIe to drain in this way. A more rationa method of drainage is reported in the foIIowing: 134
NEW SERVESVOL. XLIII,
No. I
CASE
Ross-Suppurative
REPORT
The patient, a young boy aged 5 years, (#2530) had been heahhy with the exception of whooping cough fourteen months previous.
Pericarditis
American Journal of Surgery
I
35
350 c.c., was removed by aspiration. This pus had the consistency and approximateIy the color of miIk or very thin cream. CuItures were taken. The child immediateIy was reheved.
FIG. 3. The
smaII figure shows the incision. The larger figure shows the incision retracted to discIose the anatomy invoIved. The ends of the Costa1 cartilages may be removed if additiona space is required.
The present ihness had begun tweIve days before with sore throat and a generaIized malaise, resembIing inff uenza. The chiId became very short of breath and somewhat cyanosed and had to be propped up to get his breath. The attending physician stated that for four days he had heard a rub which he thought was pericardia1. The patient was sent to the Queen of Angels Hospital. An x-ray picture showed a shadow which was obviousIy the heart, but because the pericardiophrenic angIe was not obIiterated, it was thought at first that it might be a very large heart. (Fig. I.) However, the needIe was inserted in the fifth space, midcIavicuIar line on the Ieft side, and a large quantity of pus, about
Aspiration was repeated on the following day, getting the same Iarge quantity of fluid. On the third day the boy was operated on. Operation. Local infiltration of r per cent novocaine was the only anesthesia used. The incision was about 4 inches Iong through the costosterna1 angIe, continuing up over the ribs about I inch and verticaIIy downwards over the rectus muscIe. The incision was carried through the anterior sheath of the rectus, and the rectus muscIe was spIit and retracted. This exposed the posterior sheath of the rectus, made up of the transversalis, which is muscular in this particuIar place. (Fig. 3,) Continuing in the angIe between the xiphoid process of the sternum and the Costa1 cartiIages, the finger
136
American Journal of Surgery
Ross-Suppurative
comes into a trianguIar space bounded by the sterna1 attachment of the diaphragm, the posterior sheath of the rectus and the Costa1 at-
Pericarditis
JANUARY, ,939
tinuous with the posterior sheath of the rectus. The finger may fee1 the pericardium, and if directed backwards and downwards, may fee1
FIG. 4. SagittaI section (diagrammatic) to show how the pericardium in the triangular space.
comes to the surface
FIG. 5. The finger is inserted through the trianguIar space and hooked over the upper free border of the diaphragm, pressing on the pericardium.
tach ment of the diaphragm. (Figs. 4 and 3.) Con1 tinuin lg up in this area, the finger passes over a rou .nded edge which represents the upper bord .er of the diaphragm where it becomes con-
the upper free border of the diaphragm. It may be noted that upwards through this area is continuous with the anterior mediastinum which is not definiteIy waIIed off, the pIeura
NEW SERIES VOL. XLIII, No. I
Ross-Suppurative
Iungs coming down on either side. The writer, therefore, did not open the pericardium at this stage but packed the area with gauze to promote adhesions in the anterior mediastinum. The gauze kept the wound open in the rectus,
and
the Iower part of which was sutured. On the foIIowing day it was a simple procedure to remove the gauze and then open the pericardium. The finger was inserted to break down adhesions in the pericardial cavity, but in this case there did not appear to be any. A soft tube was guided into the pericardium and down posteriorIy to the heart into the obIique sinus, with a stitch in the fascia to hoId the tube in position. A large quantity of pus was evacuated. The patient Ieft the tabIe in good condition. He was much improved; a second x-ray showed the pericardium to be smaher. (Fig. z.) The tube was removed forty-eight hours after the operation, early removal being prompted by the fact that the tube was rubbed by the heart at each beat. The pericardium continued to drain we& the action of the heart apparently forcing the fluid out. On the second day the patient was pIaced on his face to aIIow the best possibIe postura1 drainage-this is considered to be a very important feature. Drainage graduaIIy became less and ceased on the tenth postoperative day. ApparentIy no recurrence of ffuid in the pericardium occurred and subsequent x-rays showed on enlargement of the heart. The patient did deveIop some duIness in the base of the Ieft Iung and some pIeuritic effusion was present, but this absorbed without aspiration. P&e and temperature came down to normal. The chiId returned home on the thirty-fifth day. Follow-Up. The boy has done exceedingIy
we11 and is reported years later.
in exceIlent heaIth two
Pericarditis
American
~~~~~~~d surgery
I 37
Bacteriology. The report of Dr. Roy W. Hammack is as foIIows: “FIuid examined is pericardial. Genera1 characteristics: Iarge amount of thick green pus. “Method of examination. Gram stain of the smear showed numerous pus cells and a few smaI1 Gram-negative baciIIi. CuItures, June 20 and June 22, 1935, were made on Rosenow’s bIood and bIood-agar pIates. A growth of nonmotiIe Gram-negative short, ova1 bacilIus deveIoped in the brain broth cuIture in twentyfour hours. No growth occurred on the bIood agar plates. “After transpIanting severa times in brain blood to which a smaI1 amount of steriIe bIood was added, a more Iuxuriant growth developed. “ConcIusion: no change in carbohydrate media. This organism has the appearance of B. pertussis.” SUMMARY I. A case of puruIent pericarditis successfuhy treated by operation is reported. 2. Emphasis is placed on the value of draining these patients by spIitting the rectus muscIe and approaching the pericardium from beIow, thus giving dependent drainage to the obIique sinus. 3. It is dangerous to try to treat these cases by repeated aspiration. 4. EarIy remova of the Penrose drain or tube from the pericardium is urged. 3. Emphasis is pIaced on the importance of postura1 drainage. It has been stated that these cases wiI1 drain we11 by postura1 drainage aIone. 6. The author has described the anatomic relations which enter into this discussion.
E. Ross,
M.D.,
PERICARDITIS
F.R.C.S.
(ENG.),
F.R.C.S.
(ED.),
F.A.C.S.
Ross-Loos MedicaI Group LOS ANGELES, CALIFORNIA
Introduction. Suppurative pericarditis is much more common than is ordinariIy thought. Most cases, however, are found
of the right auricIe. When aspiration is necessary, it is the writer’s beIief that the fifth interspace in the midcIavicuIar Iine
FIG. I. Shows the tremendous enIargement of the heart shadow. Note the unusual persistence of the pericardio-phrenic angle on the right side.
FIG. z. The cardiac shadow is much reduced in comparison with Figure I.
as a compIication to pneumonia, and are usuaIIy discovered at autopsy. Since cases cIinicaIIy diagnosed and successfuIIy treated are comparativeIy rare even yet, I presume to report this case. Another reason is to outIine and emphasize certain factors, and particuIarIy to recommend a surgica1 approach which, aIthough it is not new, has not generaIIy been adopted. Treatment of puruIent pericarditis is necessariIy surgica1. It is permissibIe to aspirate for diagnostic purposes and possibIy for paIIiative treatment. Technique of Aspiration. It may be noted that when the pericardium fiIIs with pus the heart “ fIoats” forward; therefore a needIe, when introduced, may easiIy enter the heart muscIe or may damage one of the coronary vessels. Aspiration is sometimes done to the right of the sternum and in this area the needIe might even tear the thin auricuIar waI1
is the safest. The needIe is directed upwards and sIightIy outwards to keep the point from approaching the heart itseIf. It is quite obvious that this method couId not possibIy drain adequateIy the posterior part of the pericardium, known as the obIique sinus. Dijkulties of Draining the Pericardium. Drainage of the pericardium usuaIIy is accompIished by resecting a portion of the Costa1 cartiIages of the fourth or fifth ribs near the sternum, opening the pericardium and inserting a rubber tube or Penrose drain. This obviousIy gives ineficient drainage, since adhesions form readiIy and, as pointed out above, the heart rides forward against the anterior pericardia1 waI1. It is rather a far cry to the Iarge dependent sac behind the heart caIIed the obIique sinus, which is difficuIt or impossibIe to drain in this way. A more rationa method of drainage is reported in the foIIowing: 134
NEW SERVESVOL. XLIII,
No. I
CASE
Ross-Suppurative
REPORT
The patient, a young boy aged 5 years, (#2530) had been heahhy with the exception of whooping cough fourteen months previous.
Pericarditis
American Journal of Surgery
I
35
350 c.c., was removed by aspiration. This pus had the consistency and approximateIy the color of miIk or very thin cream. CuItures were taken. The child immediateIy was reheved.
FIG. 3. The
smaII figure shows the incision. The larger figure shows the incision retracted to discIose the anatomy invoIved. The ends of the Costa1 cartilages may be removed if additiona space is required.
The present ihness had begun tweIve days before with sore throat and a generaIized malaise, resembIing inff uenza. The chiId became very short of breath and somewhat cyanosed and had to be propped up to get his breath. The attending physician stated that for four days he had heard a rub which he thought was pericardia1. The patient was sent to the Queen of Angels Hospital. An x-ray picture showed a shadow which was obviousIy the heart, but because the pericardiophrenic angIe was not obIiterated, it was thought at first that it might be a very large heart. (Fig. I.) However, the needIe was inserted in the fifth space, midcIavicuIar line on the Ieft side, and a large quantity of pus, about
Aspiration was repeated on the following day, getting the same Iarge quantity of fluid. On the third day the boy was operated on. Operation. Local infiltration of r per cent novocaine was the only anesthesia used. The incision was about 4 inches Iong through the costosterna1 angIe, continuing up over the ribs about I inch and verticaIIy downwards over the rectus muscIe. The incision was carried through the anterior sheath of the rectus, and the rectus muscIe was spIit and retracted. This exposed the posterior sheath of the rectus, made up of the transversalis, which is muscular in this particuIar place. (Fig. 3,) Continuing in the angIe between the xiphoid process of the sternum and the Costa1 cartiIages, the finger
136
American Journal of Surgery
Ross-Suppurative
comes into a trianguIar space bounded by the sterna1 attachment of the diaphragm, the posterior sheath of the rectus and the Costa1 at-
Pericarditis
JANUARY, ,939
tinuous with the posterior sheath of the rectus. The finger may fee1 the pericardium, and if directed backwards and downwards, may fee1
FIG. 4. SagittaI section (diagrammatic) to show how the pericardium in the triangular space.
comes to the surface
FIG. 5. The finger is inserted through the trianguIar space and hooked over the upper free border of the diaphragm, pressing on the pericardium.
tach ment of the diaphragm. (Figs. 4 and 3.) Con1 tinuin lg up in this area, the finger passes over a rou .nded edge which represents the upper bord .er of the diaphragm where it becomes con-
the upper free border of the diaphragm. It may be noted that upwards through this area is continuous with the anterior mediastinum which is not definiteIy waIIed off, the pIeura
NEW SERIES VOL. XLIII, No. I
Ross-Suppurative
Iungs coming down on either side. The writer, therefore, did not open the pericardium at this stage but packed the area with gauze to promote adhesions in the anterior mediastinum. The gauze kept the wound open in the rectus,
and
the Iower part of which was sutured. On the foIIowing day it was a simple procedure to remove the gauze and then open the pericardium. The finger was inserted to break down adhesions in the pericardial cavity, but in this case there did not appear to be any. A soft tube was guided into the pericardium and down posteriorIy to the heart into the obIique sinus, with a stitch in the fascia to hoId the tube in position. A large quantity of pus was evacuated. The patient Ieft the tabIe in good condition. He was much improved; a second x-ray showed the pericardium to be smaher. (Fig. z.) The tube was removed forty-eight hours after the operation, early removal being prompted by the fact that the tube was rubbed by the heart at each beat. The pericardium continued to drain we& the action of the heart apparently forcing the fluid out. On the second day the patient was pIaced on his face to aIIow the best possibIe postura1 drainage-this is considered to be a very important feature. Drainage graduaIIy became less and ceased on the tenth postoperative day. ApparentIy no recurrence of ffuid in the pericardium occurred and subsequent x-rays showed on enlargement of the heart. The patient did deveIop some duIness in the base of the Ieft Iung and some pIeuritic effusion was present, but this absorbed without aspiration. P&e and temperature came down to normal. The chiId returned home on the thirty-fifth day. Follow-Up. The boy has done exceedingIy
we11 and is reported years later.
in exceIlent heaIth two
Pericarditis
American
~~~~~~~d surgery
I 37
Bacteriology. The report of Dr. Roy W. Hammack is as foIIows: “FIuid examined is pericardial. Genera1 characteristics: Iarge amount of thick green pus. “Method of examination. Gram stain of the smear showed numerous pus cells and a few smaI1 Gram-negative baciIIi. CuItures, June 20 and June 22, 1935, were made on Rosenow’s bIood and bIood-agar pIates. A growth of nonmotiIe Gram-negative short, ova1 bacilIus deveIoped in the brain broth cuIture in twentyfour hours. No growth occurred on the bIood agar plates. “After transpIanting severa times in brain blood to which a smaI1 amount of steriIe bIood was added, a more Iuxuriant growth developed. “ConcIusion: no change in carbohydrate media. This organism has the appearance of B. pertussis.” SUMMARY I. A case of puruIent pericarditis successfuhy treated by operation is reported. 2. Emphasis is placed on the value of draining these patients by spIitting the rectus muscIe and approaching the pericardium from beIow, thus giving dependent drainage to the obIique sinus. 3. It is dangerous to try to treat these cases by repeated aspiration. 4. EarIy remova of the Penrose drain or tube from the pericardium is urged. 3. Emphasis is pIaced on the importance of postura1 drainage. It has been stated that these cases wiI1 drain we11 by postura1 drainage aIone. 6. The author has described the anatomic relations which enter into this discussion.