The Surgical Treatment of Suppurative 
Pericarditis. 
BY 
JOHN B. ROBERTS, A.M., M.D., 
PROFESSOR OF SURGERY IN THE PHILADELPHIA POLYCLINIC AND IN THE 
WOMAN’S MEDICAL COLLEGE OF PENNSYLVANIA 
Contribution from the Surgical Laboratory of the Philadelphia Polyclinic.') 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
December, 1897. Extracted from The American Journal of t|ie Medical Sciences, December, 1897. 
THE SURGICAL TREATMENT OF SUPPURATIVE 
PERICARDITIS.1 
PROFESSOR OF SURGERY IN THE PHILADELPHIA POLYCLINIC AND IN THE WOMAN’S MEDICAL 
COLLEGE OF PENNSYLVANIA. 
By JOHN B. ROBERTS, A.M.,M.D., 
(A Contribution from the Surgical Laboratory of the Philadelphia Polyclinic.) 
The invitation to open the discussion on this topic has been accepted 
with pleasure, because I have long been interested in pericardial sur- 
gery. Studies made some twenty years ago convinced me that effusions 
in the pericardium should be treated by surgical measures similar to 
those adopted in pleural accumulations. At that time (1876) I sug- 
gested that purulent pericarditis be treated by the insertion of a drain- 
age-tube into the pericardial cavity.2 The proposal was thought by 
many to be rash and unworthy of surgical consideration. 
Rosenstein, however, adopted this method of dealing with the disease 
in 1879, and saved his patient. He was followed by West, in 1882, 
with equally gratifying success. It has been supposed that these were 
the earliest recorded cases in which suppuration within the pericardium 
had been treated by incision and permanent drainage. Within a few 
weeks, however, I have found reported* the case of Hilsmann. (Case 
No. 1 in table.) He operated in 1844 upon a man who had been sick 
about eight months, and evacuated several tumblerfuls of pus by an 
incision in the fourth intercostal space. The opening was kept patulous 
by the frequent insertion of a probe. The patient recovered. Langen- 
beck,4 in 1850, treated with similar success a purulent pericarditis 
occurring subsequent to necrosis of the ribs due to gunshot-fracture. 
{Case No. 2 in table.) 
I reached the conclusion in 18815 that pericardial incision and suture 
of cardiac wounds might be successfully accomplished, and should be 
1 Read at the meeting of the American Surgical Association, May 4,1897. 
2 New York Medical Journal, December, 1876. Idem, April, 1877, p. 384. Paracentesis of the 
Pericardium, Philadelphia, 1880, p. 55. 
3 Ueber die Paracentese des Pericardiums. F. A. Hilsmann, Kiel, 1875. 
4 Vorlesungen iiber Akiurgie, Berlin, 1888, p. 449. 
6 Annals of Anatomy and Surgery, Dec., 1881, p. 250, and Medical News, January 13,1883. 2 
ROBERTS: SUPPURATIVE PERICARDITIS. 
undertaken. Dalton,1 within recent years, successfully resected six 
inches of the fourth rib for stab-wound of the pericardium and sutured 
the pericardial sac with a continuous catgut suture. 
Williams2 successfully ligated wounded internal mammary vessels and 
stitched the pericardium in a patient who had been stabbed and received 
a wound of the heart-wall. He resected part of the fifth cartilage. The 
patient was well over three years later. Schnitzler3 protected a torn 
pericardium with iodoform gauze when suturing was difficult. The 
pericardium has been torn and the heart exposed during the resection 
of the thoracic wall for chondroma, and recovery has followed. Rehn 
recently showed,4 at a meeting of German surgeons, a man upon whom 
he had fourteen days previously sutured a stab-wound of the right ven- 
tricle after costal resection and enlargement of the pericardial wound. 
A stab-wound perforating the pericardium, going through the diaphragm 
and injuring the liver, was treated successfully by Bouflleur,5 who opened 
the abdomen and sutured the diaphragm. Ferraresi6 resected three 
costal cartilages in a wound of the mammary artery and heart, and 
used gauze, applied with moderate pressure, to restrain the bleeding from 
the heart-wall. The injury of the cardiac muscle was not deep. His 
patient recovered. 
These reports prove that the pericardium and heart do not resent a 
properly conducted surgical attack, and render a discussion of the topic 
selected valuable.7 
Perioardotomy and provision for thorough drainage are always 
demanded by the presence of pus in the pericardial sac. The etiology 
of the purulent condition should have no influence in deciding the 
question of treatment. 
The suppurative pericarditis may be primary—a rare condition,—it 
may be secondary to serous or hemorrhagic pericarditis, to suppurative 
pleuritis or mediastinitis, to septic processes in distant regions, or to 
trauma; but the surgical indication is unvarying. Tubercular peri- 
carditis, and pyopericardium, due to rupture into the pericardium of an 
abscess situated below the diaphragm8 or elsewhere, require in the same 
way pericardotomy and removal of the puruloid or purulent accumula- 
tion. 
The accessory treatment must be varied in accordance with accompa- 
nying general or local deviations from the physiological state. Rheu- 
1 Annals of Surgery, 1895, xxi. p. 147. 
2 New York Medical Record, March 27,1897, p. 437. 
3 Rullier in Arch, de Med. et de Pharm. Militaire, January, 1896, p. 110. 
4 Medical News, December 5,1896. 
5 Chicago Clinical Review (1892-93), i. p. 30. 
6 Gazz. Med. di Roma, 1896, xxii. p. 29. 
7 Parrozzani has recently cured by suture of the heart a case of penetrating stab-wound of 
the left ventricle. Reported by Brock in Lancet, July 31,1897, p. 260. 
* See Varga’s case, Gaceta Medina de Mexico, 1887, xxii. p. 256. ROBERTS: SUPPURATIVE PERICARDITIS. 
3 
matism, scurvy, pneumonitis, pleuritis, tuberculosis, empyema, abscess, 
and pyaemia require efficient medicinal and surgical therapeusis. The 
remedial measures employed for these conditions must never, however, 
be allowed to interfere with the instant and complete rescue of the heart 
from the dangers incident to the presence of pus in the pericardial 
cavity. 
Let the attendant administer antirheumatic, antiscorbutic, tonic, or 
other remedies, and aspirate, tap, or drain pleural sac or abscess-cavity; 
but these important measures must not delay the essential incision into 
the pericardium. 
The improbability of pus becoming absorbed is great in all suppura- 
tive lesions; caseation or absorption of puriform material in tubercular 
conditions does not generally occur. It has been said1 that small pleural 
empyemas may undergo spontaneous cure, but this is by no means 
to be expected. Modern surgery seldom suspends its activity when 
purulent or puruloid deposits in any region are to be treated Such 
deposits within the pericardium demand early evacuation even more 
imperatively. The mechanical effects of the hydrostatic pressure on 
the heart’s action and the degenerative changes indirectly produced in 
the cardiac muscle must be averted. 
The diagnosis of pericardial exudation is made by the physical signs 
and the symptoms. That the fluid in the pericardium is pus must 
usually be demonstrated by exploratory aspiration. When this con- 
firmatory evidence has been obtained, pericardotomy is to be performed 
with as little delay as is commensurate with satisfactory operative facili- 
ties. 
Thick pus, shreds of floating lymph or false membrane, or a needle 
of too small calibre may interfere with the demonstration expected by 
the use of aspiration. Under such circumstances the surgeon may be 
pardoned for delaying operative treatment a little while. A few days’ 
time, not more, may be given to further study and therapeutic expec- 
tation ; then an exploratory incision down to the pericardium must be 
made if the physical signs continue to suggest effusion. 
Purulent pericarditis sometimes causes no fever and no local oedema. 
A dilated heart may present signs and symptoms so similar to pericar- 
ditis with effusion that inspection of the heart or its surrounding sac 
may be the only means of ascertaining the truth. I recommended diag- 
nostic incision in such obscure cases as long ago as 1881,2 and have 
seen no reason to change my opinion as to its value and desirability. 
If there is a probability, therefore, that the patient’s urgent symptoms 
are due to either pericardial effusion or cardiac dilatation, and compe- 
tent medical examiners cannot determine the exact lesion, exploratory 
1 Parker, Trans. London Clinical Soc , 1889, xxii. p, 66. 
2 Annals of Anatomy and Surgery, December, 1881, p. 250. 4 
ROBERTS: SUPPURATIVE PERICARDITIS. 
incision is to be adopted. If this establishes the fact of effusion, 
puncture of the exposed pericardium will prove or disprove the exist- 
ence of pus or serum. If pus be found, an incision should be made 
and permanent drainage established by stitching the pericardium to the 
skin or inserting tubular or gauze drains. Should the effusion prove to 
be serous, the puncture may be utilized to evacuate the entire quantity 
of effusion, and drainage may be omitted. The fluoroscope and skia- 
graphs will sometimes aid in diagnosis of obscure cases, but the appa- 
ratus is not always obtainable. 
There is little dissent from the opinion that purulent accumulations 
in all regions require surgical intervention, lest the patient die of septic 
sequences or the pus be evacuated into neighboring cavities before nature 
can provide for its spontaneous exit. The supposed vulnerability of the 
heart long prevented the application of this principle of treatment to 
the pericardium. As a consequence, patients died with several pints ot 
pus in the pericardium,1 and autopsies sometimes revealed a burrowing 
sinus, reaching nearly to the surface; proving that the imprisoned pus 
was vigorously endeavoring to escape, that life might be saved. 
Numerous recorded cases show the inutility in purulent cases of tap- 
ping, even if repeated. Gooch2 tapped a case six times and injected 
iodine solution. The patient died in thirty-eight days. The survival 
for such a long period suggests that the boy might have been saved if 
the purulent fluid had been evacuated by incision at the first operation. 
In a case reported by Doubleday3 seventeen pints of pus were withdrawn 
from the pericardium by ten aspirations in the course of thirty-four 
days ; then death occurred. In Villeneuve’s case4 recovery subsequent 
to pericardicentesis occurred after the persistence of a fistule at the seat 
of operation for nearly six months. The effusion was originally serous, 
but became purulent. 
Death occurring after tapping has revealed great quantities of pus 
still in the pericardial sac, though large amounts had previously been 
removed. Smith found5 thirty-six fluidounces at autopsy, though thirty 
fluidounces of pus had been withdraivn by aspiration. In some cases 
the original accumulation had been incompletely withdrawn; in others 
more pus had formed and had been denied escape because no perma- 
nent opening had been provided. In an autopsy made by Parker, in 
a case not operated upon, the distended pericardium reached to the 
1 In the New York Medical Record, March 9,1895, p. 314, is recorded a case in which 2600 c.c. 
of pus and lymph were found at autopsy. See also Brit. Med. Journal, December 1, 1888, 
p. 1219; Gaz. Hebdom. de Med. et de Chir., January 12,1883, p. 25, and Brit. Med. Journal, 1885, 
i. p. 1246. 
2 Brit. Med. Journal, June 19, 1875. 
3 New York Med. Journal, September 1,1888, p. 232. 
4 London Med. Rec , September 15,1875, p. 532. 
6 New York Med. Rec., February 12,1876, p. 110. ROBERTS: SUPPURATIVE PERICARDITIS. 
5 
anterior vertical axillary line on both sides and “sat like a saddle upon 
the lungs.”1 
Such observations show that aspiration and puncture afford only tem- 
porary relief in suppurative pericarditis, and that a free exit for the 
pus must be maintained for a varying length of time, until the internal 
surfaces of the cavity become modified or mutually adherent. The 
entrance of air into the pericardium during this time does no harm. 
Drainage of the pus may be maintained by stitching the incised 
pericardium to the edges of the cutaneous wound, by the insertion of 
drainage-tubes, or by the introduction of a gauze wick, which must 
be frequently renewed. Stitching the pericardium to the edges of the 
wound has the advantage of possibly preventing pus leaking into the 
pleural sac, if it has been opened by the surgeon during the pericar- 
dotomy. The method of operating which I recommend avoids this 
contingency. If, however, the pleura is cut, suture of pericardium to 
the skin is a judicous procedure when it can be done, for there is little 
doubt that secondary pleuritis, due to infection from leakage of the 
pericardial pus, is a real danger. Delorme and Mignon report2 a case 
of suppurative pericarditis which died after tapping with a trocar in the 
fifth interspace 6 cm. to left of the sternal border. Pleuritis occurred 
suddenly after the pericardial tapping. Autopsy showed that the pleura 
had been wounded, and the pus in the pleural sac had similar bacterio- 
logical characteristics to that in the pericardium. 
If the pleura is known not to have been punctured, drainage by a 
large but short rubber tube is probably the best method. It does not 
need renewal as does the gauze wick, and can be utilized for irrigation 
if the surgeon decides to use irrigation. Two short drainage-tubes, 
placed side by side, like the barrels of a double-barrel shotgun, are the 
most satisfactory in cases where irrigation is to be employed. The 
cleansing or antiseptic fluid is then allowed to flow in through one 
tube and out through the other, as in washing out the bladder by a 
two-way catheter. The catastrophe which happened in Parker’s case 
(No. 14 in the table) would not then be likely to occur. His patient 
apparently died from pressure on the heart made by the irrigating fluid 
failing to escape from the pericardial sac. 
The prognosis after incision and drainage is good, provided the 
operation is done early and no serious complications have preceded or 
followed the surgical treatment. West saw his first case nine years 
later in good health, and Davidson’s case had no cardiac or pul- 
monary symptoms when seen nine months after operation. Many 
of the cases of death recorded in the subjoined table are attributable to 
pysemic infection, of which the pyopericardium was a mere incident. 
1 Trans. Clinical Soc., London, 1889, xxii., p. 63. 
2 Revue de Chirurgie, 1895, xv. p. 1016. ROBERTS: SUPPURATIVE PERICARDITIS. 
The relief due to the evacuation of the pus was great, but naturally it 
alone could not restore the patient to health, and he died of his general 
disease. In some cases death would probably have been averted if the 
pericardial condition had been promptly and efficiently treated. Delay 
causes myocarditis, cardiac debility, and exhaustion of the patient in 
secondary suppurative pericarditis; and in primary suppuration within 
the pericardium gives opportunity for general septic infection in addi- 
tion to these risks. 
The combination of pleuritis and pericarditis is quite frequent. It is 
probable that either may be the primary condition, leading to the other 
as a secondary inflammation by contiguity of structure or continuity of 
vascular connection. The histories in the table seem to show that, in 
some instances at least, the pleuritis has been caused by the surgeon’s 
pericardial puncture or incision being made through the pleural sac, 
and thereby permitting its direct infection from the pus in the pericar- 
dium. This can be avoided in nearly every case by a properly planned 
operative attack. 
The prognosis is sure to be bad in cases where delay has permitted 
enormous quantities of pus to distend the long-suffering pericardial sac, 
the patient’s strength to be exhausted, his kidneys congested, the car- 
diac muscle degenerated, and perhaps the pericardial pus evacuated by 
ulceration into the bronchial tubes.1 
The results obtained by incision and drainage in tubercular perito- 
nitis suggest that drainage in tubercular pericarditis may lead to a per- 
manent cure. The ease with which the pericardium can be irrigated 
Avith solutions of iodoform would seemingly add to this probability of 
success. 
Results. In the table of thirty-five cases of suppurative pericar- 
ditis of all kinds treated by incision fifteen recovered and twenty died. 
This gives a ratio of recovery of nearly 43 per cent. Of the fatal cases 
ten at least Avere evidently septic before operation. Excluding those 
known to be septic, only ten died out of the thirty-five cases. Of these 
ten there are complications, such as purulent pleuritis, or pleural, pul- 
monary, renal, or cardiac lesions mentioned in every instance except 
one, in which no statement is made (Case 28). Such a shoAving is very 
satisfactory when it is known that Avithout operation practically all 
cases die, and that AA7ith repeated aspiration nearly eArerv case reported 
has terminated fatally. The experience of Fiedler2 and others s1ioaats 
that this statement is true. 
In a few cases, as in that of Villeneuve,8 aspiration has been followed 
by recovery because nature established drainage by the formation of a 
1 Allende’s case. Revista de la Sociedad Medica Argentina, 1895, iv. p. 20. 
2 Sammlung Klinischer Vortrage, innere Medicin, 1881, No. 72. 
8 London Medical Record, September 15,1875, p. 532. ROBERTS: SUPPURATIVE PERICARDITIS. 
7 
fistule. Doubleday1 states that Wyss reports a case of pyopericarditis 
in which a fistule formed spontaneously and lasted for years. Death 
finally occurred from an attack of acute pericarditis. In Newman’s 
case (No. 9 of table) aspiration wTas repeatedly performed; but after a 
month of this palliative treatment drainage and subsequently incision 
were adopted. When death occurred, a few days later, it was discovered 
that nature had been endeavoring to supplement the surgical treatment 
by establishing in the second interspace a fistule from the pericardium 
to the surface. The canal had reached the subcutaneous tissue, but had 
not yet perforated the skin. This case shows nature’s contempt for 
anything less than complete evacuation of purulent effusions, and is an 
indication that the proper surgical treatment in suppurative pericarditis 
is incision and drainage. 
It is true that Douglas2 reported a case of pus in the pericardium, 
treated by simple aspiration, that had not died up to the time of the 
report. The report, however, was made only thirty days after opera- 
tion, and then the patient was expectorating purulent matter, due pos- 
sibly to a communication between the pyopericardium and bronchial 
tubes. This case, therefore, affords no argument in favor of delaying 
incision and drainage. Langenbeck mentions3 a case which was cured 
after the use of the trocar, but he gives no details. The trocar may 
have been so used as to permit permanent drainage. 
Incision has also the advantage of reducing to a minimum the danger 
of wounding the heart. This organ has been punctured on a number 
of occasions in attempts to tap a distended pericardium with a trocar 
or an aspirating needle. Sometimes this has occurred from a mistaken 
diagnosis. It may also happen, however, because the heart has become 
adherent to the anterior wall of the pericardium. Even with such 
adhesion a large and dangerously oppressive effusion may exist behind 
and at the sides of the heart. Diagnosis may then be difficult, because 
the heart-sounds will not be muffled. 
Barlow reports4 experimental punctures made after death on two 
cases of pericardial effusion. All the punctures made to the left of 
the sternum resulted in the aspirating needle entering the heart-wall 
and obtaining no fluid; but punctures made at the right side of the 
sternum reached the effusion without cardiac injury. The distinctness 
of the heart-sounds during life induced him to hesitate in adopting peri- 
cardicentesis, for the diagnosis was not certain. If he had aspirated in 
1 New York Medical Journal, September 1,1888, p. 232. 
2 Trans Detroit Medical and Library Association, January, 1879, and Paracentesis of the 
Pericardium. John B. Roberts, Philadelphia, 1880, p. 93. 
3 Vorlesungen tiber Akiurgie, Berlin, 1888, p. 450. 
4 British Medical Journal, December 1,1888, p. 1220. See also Churton, Trans. Clinical Soc 
of London, xxv. p. 43. 8 
ROBERTS: SUPPURATIVE PERICARDITIS. 
the usually accepted locations, he would have injured the heart and 
would have obtained no fluid; if, however, he had adopted incision as 
recommended in this paper, the diagnosis would have been cleared up, 
the fluid found, and the lives of the patients possibly saved. 
Money relates1 a very remarkable case where at autopsy twenty-four 
fluidounces of pus were found in the pericardium, “ almost entirely 
stowed away behind the heart.” The amount was not appreciated, even 
when the chest was opened, until the heart was moved. I and others 
have invented peculiar aspirating needles to avoid wounding the heart, 
when the effusion has been nearly all evacuated ; but these devices will 
not avert puncture of an adherent heart or evacuate serum or pus con- 
fined behind the heart by intrapericardial adhesions. 
Delorme and Mignon found2 in one of their dissections a vein of such 
size lying on the front of the pericardium that a free hemorrhage would 
have resulted from its puncture. Such a complication is avoided by 
operating by an incision, which also prevents injury to the internal 
mammary veins and artery, should they be unusually located. 
These observations and other reported cases not here mentioned have 
almost convinced me that incision is better than aspiration even in 
cases not supposed to be purulent. It establishes diagnosis in dubious 
cases, avoids cardiac injury, saves the pleura from puncture, affords 
complete evacuation of effusion, permits extraction of thick pus and 
membranous lymph, and gives opportunity for disinfection of the sac 
when that is necessary. Rullier3 found it necessary to finally incise 
and drain a serous pericarditis which he had previously aspirated four 
times, even following the aspiration on two occasions with injection of 
tincture of iodine. The incision was done under local anaesthesia with 
cocaine. The patient recovered. 
Irrigation has been adopted as an adjunct to incision in a number 
of cases. No immediate harm has seemed to result except in Parker’s 
case (No. 14); the child in that instance died during the irrigation, 
immediately after the incision, apparently from pressure on the heart 
exerted by the irrigating fluid. Irrigation was used to encourage the 
evacuation of the thick pus, which did not flow well; but the water 
did not escape on account of the pericardial opening becoming plugged 
with thick pus or membranous lymph. The child was pysemic, and the 
heart, which was very weak, stopped beating. 
It is certainly essential that the outflow of fluid be unimpeded when 
irrigation is employed. The fact that plugging, sufficient to prevent 
the escape of the irrigating fluid, occurred in this case would seem to 
indicate that something more than an incision was needed to empty the 
1 Lancet, Octboer 18,1890, p. 818. 
2 Revue de Chirurgie, 1895, p. 829. 
3 Arch, de Med. et de Chirurgie Militaire, January, 1896, p. 7. ROBERTS: SUPPURATIVE PERICARDITIS. 
9 
pericardium of the fibio-purulent material clogging the heart’s action. 
Parker believes that he would have done better if he had given the 
heart a little time to recover strength after the first gush of pus before 
endeavoring to clear out the sac by irrigation. This would probably 
have been judicious. 
The opinion of Sievers1 that irrigation tends to produce adhesions 
and may delay convalescence is difficult to accept. The occurrence of 
intrapericardial adhesions to a greater or less extent would seem usu- 
ally probable in suppurative pericarditis treated by evacuation; but 
case No. 18 seems to indicate that they need not occur. 
More than one autopsy, made a long time after recovery from peri- 
cardicentesis, in non-suppurative cases, has shown the presence of 
adhesions. These were formerly thought to be the essential of cure. 
Pepper’s case2 showed complete adhesion fifteen months after aspiration. 
Irrigation carefully performed with warm fluid gradually admitted to 
the pericardium, and given free vent by using two parallel drainage- 
tubes in the wound, ought to be beneficial in ridding the cavity of 
shreds of lymph and pus, and may perhaps modify the walls of the 
sac. I should prefer sterile salt solution at about 100° or 105° F., 
and would use it in cases in which there was much lymph mixed with 
the pus. If the heart is very weak, it may be wise to wait for a few 
hours after the pericardotomy. Daily repetition of the irrigation seems 
desirable if the drainage instituted does not keep the sac empty. 
Weak antiseptic solutions are unobjectionable for irrigation, but prob- 
ably unnecessary. It has been suggested that the reflex irritability of 
the heart is modified by the false membranes, and that consequently 
irritants applied by irrigation cause little cardiac disturbance. 
I would not inject solution of hydrogen dioxide into the sac, lest the 
effervescence within the cavity cause injurious cardiac pressure. 
The direct extraction of shreds and membranous sheets by fingers and 
forceps is certainly judicious, when they can be seen or felt. Explora- 
tion of the interior of the pericardium with the finger and palpation of 
the heart itself are not objectionable under appropriate circumstances. 
If the pyopericardium is one in which the pus is free from lymph and 
flows freely, irrigation may be unnecessary. 
The situation at which the pericardium should be opened by simple 
tapping and by open incision deserves careful attention. In a former 
study3 I reached the conclusion that the best two points for pericardi- 
centesis were close to the base of the ensiform cartilage, in the fossa 
between it and the seventh left costal cartilage and the fifth left inter- 
1 Zeitsch. fiir klin. Med., 1893, xxiii. p. 45. 
2 Paracentesis of the Pericardium, John B. Roberts, Philadelphia, 1880, p. 79, and New York 
Medical Journal, December, 1876. 
3 Paracentesis of the Pericardium, Philadelphia, 1880, pp. 65 and 67. 10 
ROBERTS: SUPPURATIVE PERICARDITIS. 
costal space, at from 5 to 6 cm. (2 to 21 inches) to the left of the median 
line of the sternum. Of these two points preference was given to the 
latter for aspiration, even though its selection rendered perforation of 
the pleural cavity almost certain ; but the importance of avoiding pleural 
injury in cases treated with a drainage-tube was recognized. 
The puncture near the ensiform cartilage was regarded as an efficient 
route to the pericardium and one pretty sure to make the needle enter 
the pericardium without wounding either pleural sac. The chief risk 
in this location, perhaps, is that the diaphragm may be punctured if 
pericardial effusion is not present or if the surgeon does not direct the 
needle a little upward as he perforates the thoracic wall. Rotch’s point 
in the fifth interspace, at to 5 cm. to the right of the edge of the 
sternum, is objectionable because it opens the right pleura. 
The danger of infecting the left pleural cavity by the pus within a 
pyopericardium, when the pericardium is punctured or incised in a 
location which causes a penetrating wound of the pleural sac, is not a 
theoretical one. This is shown by cases in which serous or suppurative 
pleuritis has arisen, after pericardicentesis or pericardotomy in the 
usually selected locations known to open the pleura.1 While it is true 
that pleuritis may occur as the primary condition and pericarditis as 
the secondary lesion, or that both may arise from the same cause, clin- 
ical and bacteriological experience seems to show that direct infection 
from the pericardium to the pleura is a real danger. It is probably 
much less real, to be sure, in cases of hydropericardium or serous peri- 
carditis than in suppurative pericarditis, since the effusion is apt to be 
less infective in character. 
Ferrand2 believes the point of election for tapping the pericardium 
to be in the fifth intercostal space, in a line vertically below the nipple, 
when the effusion is moderate; in the sixth intercostal space, on the 
same vertical line, if the signs denote a large effusion. He arrived at 
these conclusions by studying the limits of the pericardium and the 
downward displacement of the diaphragm after experimental intro- 
duction of fluid. He found that the arch of the diaphragm was low- 
ered about 2 cm. in the recumbent position when 600 grammes of 
fluid were introduced, and that the depression was 3 cm. when the 
cadaver was put in a sitting posture. With 1100 grammes of plaster 
solution in the sac the cardiac apex at the left angle of the pericardium 
was at least 6 cm. from the thoracic wall. Delorme and Mignon found3 
the pericardium to be from 3 cm. to 5 cm. from the surface of the skin 
in cadavers. 
1 British Medical Journal, December 1,1888, p. 1220; North American Journal of Homoeopathy 
New York, June, 1889, p. 392; see cases Nos. 3, 32, and 34 in table; Ashby’s case of pericardia 
tapping through lung from scapular angle is interesting; Lancet, March 29.1884, p. 560. 
* Contribution a l’Etude de la Paracentese du Pericarde, Bordeaux, 1893, p. 45. 
3 Revue de Chirurgie, December, 1895, p. 830. ROBERTS: SUPPURATIVE PERICARDITIS. 
11 
Rotch 
Roberts 
Ferrand 
Skiagraph of a cadaver, in the pericardium of which about 740 c.c. of plaster-of-Paris solution had been 
injected. Tacks were thrust into the chest at the points recommended for aspiration by Rotch, Ferrand, 
and Roberts. The nipples are marked by the buttons. 12 
EGBERTS: SUPPURATIVE PERICARDITIS. 
Ferrand’s points would puncture the pleural sac, and are, therefore, 
as unsatisfactory as that recommended by me in the fifth interspace. 
Numerous dissections made by Delorme and Mignon show1 that the 
edge of the left pleura is very variable in its relation to the left border 
of the sternum, and that the accepted points of puncture on the left side 
must often wound the pleura. This observation holds good for infants 
as well as adults. Puncture in the fifth and sixth interspace close to 
the sternum will not assure safety to the pleura, though it was formerly 
thought that here the pleura was out of harm’s way. 
That pathological lesions change the pleural relations to the pericar- 
dium very little was apparently proved by their dissection of cases 
of pericarditis and by injecting fluid into the pericardium. This is not 
surprising when it is recollected that the parietal pleura is fixed to the 
thoracic wall. 
The statement made by Fowler2 that the boundaries of the pleura are 
greatly displaced in pericardial distention is, I believe, erroneous. The 
lungs are usually displaced, and may be thrust far backward by the 
distended pericardium sitting upon them like a saddle; but the pleurae 
seem to hold their usual relations to the anterior wall. Of course, the 
two layers may in some cases become adherent by a local pleuritis, and 
thus lead to local obliteration of the pleural cavity. 
My dissections lead me to believe that Delorme and Mignon are cor- 
rect in stating that the pleura is in great danger of injury from the 
punctures usually made. The left pleura in many dissections made by 
these writers was out of the way, however, of a puncture made in the 
left xiphoid fossa. 
These considerations lead me to the conclusion that, in cases of sus- 
pected suppurative pericarditis, the exploratory aspiration to determine 
with certainty the existence of pus in the pericardium should be per- 
formed in the upper part of the left xiphoid fossa. The needle should 
be thrust upward a little and toward the median line of the sternum. 
In fat patients a small cutaneous incision should be made if it is difficult 
to locate with certainty the top of the xiphoid fossa. If this establishes 
the diagnosis, the pericardium should be incised and drained by resection 
of the fourth and fifth costal cartilages on the left side of the sternum, 
in the manner devised by me and described hereafter. 
It is probable that even in non-suppurative pericardial effusions the 
left xiphoid fossa is the place of election for aspiratory puncture ; but it 
does not afford room for incision and drainage. Hence in suppurative 
cases costal resection is to be adopted, because the pleura can then be 
readily pushed aside; the internal mammary artery, which may be as 
large as the radial, preserved from injury; and the surgeon have room 
1 Ibid., December, 1895, and January, 1896. 
2 Trans. American Surgical Association, 1896, xiv. p. 161. ROBERTS: SUPPURATIVE PERICARDITIS. 
13 
for extraction of membranes or clots, or for any intrapericardial manipu- 
lation demanding fingers or forceps. 
More than one instance is recorded where an incision or puncture 
evacuated the pericardial effusion found to exist into or through the 
left pleural cavity. In some cases the operation was performed for a 
supposed pleural effusion; but a distended pericardium was found to 
exist, and was then tapped through the original wound. The cases of 
West (No. 6), Savory (No. 7), and Gussenbauer (No. 11) are illustra- 
ions of this error of diagnosis. 
West speaks1 of a purulent pleuritis in which the needle, after being 
thrust into the pleural sac and obtaining pus, failed to perforate the 
pericardium. The pericardial symptoms diminished, and he believed 
that the pericardium had been nicked and had then drained into the 
pleura. 
Resection of the thoracic wall for obtaining access to the peri- 
cardium has been proposed or done by Ollier, Durand,2 Delorme and 
Mignon,3 and Williams.4 Durand’s operation is a modification of that 
recommended by Ollier, and consists of the following steps: 
“A cutaneous incision on the fifth costal cartilage, parallel to it and 
from 6 to 8 cm. in length. It should commence at the middle line. 
“ Isolation and rapid denudation of the cartilage with the aid of the 
bistoury. 
“ Resection of this cartilage, which should be commenced by sepa- 
rating it from its sternal attachments and raising it from within out- 
ward. 
“ To these fundamental manoeuvres is added ligature of the internal 
mammary vessels at the upper and lower borders of the wound. These 
organs are thus put out of danger of secondary ulceration or of acci- 
dental perforation during the operation. The fingers then detach the 
triangularis sterni, the operative importance of which Delorme and 
Mignon have clearly shown. The fingers are then carried toward the 
middle line under the sternum, and recognize the pleura. The distended 
pericardium is then seen. Displacement of the pleural sac is then 
attempted, the situation of which sac scarcely appears to be changed 
by the pericardial distention.” 
At this moment, if the displacement of the pleura is insufficient, or 
if the pericardium is hidden behind the sternum, the border of the 
sternum is cut away. 
“ Incision of the pericardium, which is widely accessible to sight and 
touch.” 
1 British Medical Journal, December 1,1888, p. 1220. 
3 Revue de Chirurgie, 1896, No. 6. 
3 Ibid., December, 1895, and January, 1896. 
4 New York Medical Record, March 27,1897, p. 437. 14 
ROBERTS: SUPPURATIVE PERICARDITIS. 
After some little work on the cadaver I propose the following opera- 
tion for pericardotomy : The details are, I believe, in some respects new, 
though the writers just mentioned have suggested simpler methods. 
After I had proved to my satisfaction the efficiency of the method on 
the dead subject, and its reliability in avoiding pleural wound, I was 
gratified to find that much the same method of opening the thorax had been 
used by Williams1 in a case of stab-wound requiring pericardial suture, 
which had healed favorably. His operation was not devised to prevent 
pleural injury, but to get access to a wounded internal mammary artery. 
I had supposed my method entirely novel until I recently saw his paper. 
My dead-house investigations and his experience on the living patient 
supplement each other in a way that convinces me of the admirable 
character of the operative procedure which I advocate. 
The operation consists in making a sort of trap-door, consisting of 
portions of the fourth and fifth costal cartilages, which is turned upward 
by utilizing for a hinge the soft tissues in the third intercostal space. 
A vertical incision is made about 1 cm. to the left of the median line 
of the sternum, beginning on a level with the top of the fourth costal 
cartilage. This cut is carried through the skin and subcutaneous tissue 
to the sternum, and is continued downward to a point corresponding 
with the level of the upper border of the sixth cartilage. The length 
of this incision is from 4 to 5 cm. 
A second incision is made parallel to the first, beginning at the upper 
border of the fourth rib, at from 4 to 5 cm. to the left of the commence- 
ment of the first incision. It is continued downward from the top of 
the fourth cartilage to the upper border of the sixth cartilage. The 
curve of the sixth cartilage requires this incision to extend downward a 
little further than the first vertical incision; but as the fourth rib also 
is a little concave upward, the second cut is nearly of the same length 
as the first. The second incision is made deep enough to divide all the 
tissues down to the cartilages. The lower ends of these two incisions 
are joined by a third cut carried along the upper border of the sixth 
costal cartilage. 
The soft tissues to the left2 of the first incision are separated from the 
sternum and pushed outward, so as to disclose the exact situation of the 
articulation of the fourth and fifth costal cartilages with the sternum. 
With a large scalpel, having a thick back, the fourth and fifth carti- 
lages are divided as near as possible to the sternal border in such a 
way as to leave a bevelled surface of the cartilage attached to the ster- 
num looking forward and outward. This section of the cartilages may 
be made with a Hey’s saw, if the surgeon prefers. A thick-backed 
scalpel, with a cutting edge having a large belly, will be found a satis- 
1 Loc. cit. 
2 “ Left” means the patient’s left. Author’s Chondro-plastic Method of Pericardotomy, by a Trap-door 
Excision of Costal Cartilages, which avoids Injury to the Pleura and 
Internal Mammary Vessels. 
[The flap, consisting of portions of the fourth and fifth cartilages and the attached 
soft parts, is turned upward, exposing the left lung covered with pleura and the 
internal mammary vessels. The forceps is seen holding the vessels and the edge of 
the pleural sac outward, so as to expose the white pericardium, in which an opening, 
indicated in black, has been made.] ROBERTS: SUPPURATIVE PERICARDITIS. 
15 
factory and safe instrument with which to divide the cartilages with the 
least danger to the tissues in the mediastinum. 
The next step consists in dividing the cartilages immediately under 
the outer edge of the flap in a similar manner, leaving a bevelled sur- 
face to the portion left attached to the rib, which looks forward and 
inward toward the median line. The incision is near the junction of 
the ribs with the cartilages. Care must be observed to make the incision 
through the cartilage of the fifth rib vertically under the incision in 
the cartilage above. The tendency is to bring the incision inward to- 
ward the median line of the body, so that the opening made in the chest- 
wall becomes too narrow at the bottom of the flap. 
In dividing the cartilages the operator must be cautious not to punc- 
ture the pleura, which is closely attached to the inner surface of the 
costal cartilages at the outer margin of the flap. There is less danger 
in making the costal incisions near the sternum, because in that re- 
gion the muscular fibres of the triangularis muscle are immediately 
beneath the cartilages. The surgeon, having divided the cartilages 
completely, next cuts the intercostal muscles and soft tissues in the 
fifth, fourth, and intercostal spaces and along the upper border of the 
sixth cartilage. 
The chondro-plastic flap is then carefully raised from its lower border 
and the tissues of the mediastinum are cautiously separated from the 
internal surface of the resected cartilages and the intercostal muscles. 
The trap-door is thus opened on the hinge at the upper border and 
the triangularis muscle exposed. Upon it, about 1 cm. from the border 
of the sternum, is seen the internal mammary artery and its two ac- 
companying veins running parallel to the sternal edge. At the outer 
portion of the window the muscular fibres and fascia are thinner and 
cover the lung and pleura. An incision is made through the trian- 
gularis muscle, close to the sternum and therefore within the line of the 
internal mammary vessels; and is carried up and down as far as the 
opening in the chest-wall will permit. 
With the finger or a curved blunt instrument the surgeon then sepa- 
rates the fascia and muscular fibres and pushes the outer part with the 
vessels and the double edge of the pleural sac outward toward the external 
border of the opening. The shining white surface of the pericardium 
is then seen lying behind the sternum and along the inner portion of 
the opening. The pleura, which often has considerable fat along its 
edge, like the appendages of the colon, may not be seen, because it is 
pushed out of the way without having the overlying fatty tissue sepa- 
rated from it. If it is seen, its transparency or pinkish color will 
distinguish it from the white and more opaque pericardium. 
Injury to the vessels or pleura is thus averted during the pericar- 
dotomy, because they are pushed away from the proposed opening into 16 
ROBERTS: SUPPURATIVE PERICARDITIS. 
Quantity 
Irriga- 
No. 
Operator 
Complica- 
Tapped pre- 
Situation of 
of pus 
and date. 
age. 
illness. 
tion. 
viously. 
incision. 
evacu- 
ated. 
tion. 
1 
Hilsmann, 
M. 
8 mos. 
None. 
No. 
4th inter- 
About 
No. 
1844 
25 
space, a 
finger’s 
1 quart; 
much 
breadth from 
more 
left edge of 
escaped 
sternum. 
within a 
few hours 
after ope- 
ration. 
2 
Langenbeck, 
Not 
Not 
Gunshot 
No. 
Where 5th rib 
Not 
No. 
1850 
given 
given. 
wound and 
necrosis of 
was absent. 
given. 
ribs. 
Great 
3 
Rosenstein, 
M. 
28 days 
Pleuritis. 
Twice a few 
4th inter- 
No. 
1879 
10 
days previous 
space near 
quantity. 
with aspira- 
tor; pleura 
sternum. 
4 
West, 
M. 
1 mo. 
None. 
also tapped. 
Yes, three 
5th inter- 
2 quarts. 
Carbolic 
1882 
16 
days previ- 
ously. 
space in line 
of left nipple. 
acid sol. 
1 :40 
5 
Partzevsky, 
M. 
13 wks. 
Pleuritis. 
Yes, twice. 
4th inter- 
Not 
Salicylic 
1882 (?) 
23 
space. 
given. 
acid sol. 
6 
West, 
M. 
Not 
Pleuritis, 
Not given. 
Opened with 
24 fl.oz. 
Not 
1883 
14 
given. 
pneumonia, 
abscess of 
bistoury from 
given. 
wound to 
thigh, 
evacuate sup- 
arthritis. 
posed pleural 
effusion. 
24 fl.oz. 
7 
Savory (?), 
M. 
7 wks. 
Abscess of 
No. 
5th inter- 
Yes, 
1883 
9 
shoulder and 
space in ant. 
Condy’s 
Reported by 
thigh, pleu- 
line of axilla; 
fluid. 
Brinton and 
ritis,pneumo- 
through pleu- 
Collyns. 
nia; serum 
obtain’d from 
ral cavity, 
which was 
pleura at two 
opened be- 
previous 
cause effus’n 
tappings. 
believed to 
be pleural. 
Not 
8 
Scott, 
M. 
5 wks. 
None. 
Yes, with tro- 
5th inter- 
Yes, 
1883 
6 
car one day 
space near 
given. 
carbolic 
previously; 
apex beat. 
acid sol. 
irrigation 
with carbolic 
acid solution, 
1% P- ct. 
1 per cent. 
9 
Newman (or 
M 
2 mos. 
Typhoid 
Yes, aspirated 
3d left inter- 
174 fl.oz. 
Tincture 
Stirling), 
32 
fever; 
4 times; 5th 
space; in- 
had been 
of iodine 
1885 
pleuritis. 
time a silver 
cision made 
evacu- 
(B.Ph.) 
canula for 
where fistula 
ated by 
1; 10 
drainage; 
existed from 
the five 
carb.acia sol. 
canula which 
previous 
&tinct. iod. 
had been 
tappings. 
sol. for irrig. 
draining the 
First aspira- 
tion 1 month 
sac for three 
days. 
previously. 
2 fl.lbs. ? 
10 
Mikhailov, 
F. 
About 
Pleural, 
Yes, two days 
4th inter- 
Boric 
1885 (?) 
35 
3 wks. 
bronchial, 
previously. 
space near 
acid sol. 
and renal 
sternum. 
lesions. 
11 
Gussenbauer 
M. 
Not 
Acute osteo- 
Not given. 
5th rib re- 
Not 
Thymol 
1885 (?) 
13 
given. 
myelitis at 
sect’d; open’d 
given. 
solution. 
shoulder 
(left). 
pericardium 
through pleu- 
ral cavity be- 
cause thought 
to be pleural 
effusion. ROBERTS: SUPPURATIVE PERICARDITIS. 
17 
Perma- 
nent 
drainage 
after 
incision. 
Time of 
after- 
treat- 
ment. 
Result. 
Reference. 
Remarks. 
Yes. 
Nearly 
Recov- 
Ueber die Para- 
The pericardium was opened behind the ster- 
wound 
kept 
open by 
inserting 
probe. 
3 mos. 
ery. 
centese des Peri- 
cardiums. F. A. 
Hilsmann, 
Kiel, 1875. 
(Inaug. Dissert.) 
num, though the external wound was a short 
distance to left of sternum. As the sac was 
gradually drained its walls contracted and the 
pericardial opening moved to the left. In a 
few days the opening was 1% inches to left ot 
sternum and over the 4th rib. In order to 
empty the sac thoroughly when the external 
wound was dressed the patient had to bend 
over as if he was about to stand on his head. 
Not 
Not 
Recov- 
Vorlesungen iiber 
Patient had been wounded in a duel in which 
given. 
given. 
ery. 
Akiurgie B. von 
Langenbeck, 
Berlin, 1888, 449. 
the bullet shattered five ribs. Necrosis had 
subsequently occurred and purulent pericar- 
ditis resulted. 
Yes, two 
About 
Recov- 
Berl. klin. Woch., 
Pleuritis apparently occurred after tapping and 
incision of pericardium. 
drainage 
2 mos. 
ery. 
Jan. 31, 1881, 62 
tubes. 
Yes, with 
5 mos. 
Recov- 
Med.-Chirurg. 
Rod-shaped bacteria found in pus. Patient in 
drainage 
tube. 
ery. 
Trans., 1883, 235. 
good health nine years afterward. West be- 
lieves that pericardial adhesions had occurred, 
hut there was no evidence of this condition. 
Yes, with 
drainage 
tubes. 
30 hrs. 
Death. 
London Medical 
Record, Feb. 15, 
1883, 33. 
Autopsy showed cardiac hypertrophy with tatty 
degeneration, pleural adhesions, pulmonary 
oedema. 
Not 
given. 
14 dys. 
Death. 
Brit. Med. Journ., 
Dec. 8,1883, 1129 ; 
and Feb. 21,1891, 
404. 
At autopsy found extensive pericardial adhe- 
sions. fCase of a septic nature most probably. 
—J. B. R.J 
Yes, with 
drainage 
tube. 
15 dys. 
Death. 
St.Bartholome w ’ s 
Hosp. Reports, 
1883, xix. 271. 
This patient is evidently the one referred to by 
West in Medico-Chirurgical Trans., 1883, as 
having been operated upon by Savory. Case 
was one of pyaemia. Autopsy showed no com- 
munication between left pleura and tract lead- 
ing through it to pericardium because adhe- 
sions had occurred. 
Yes, two 
Not 
Recov- 
New Zealand 
openings 
an inch 
given. 
ery. 
Med. Journ., 
July, 1891, 268. 
apart 
with 
drainage 
tube 
through 
both. 
Yes, with 
rubber 
tube. 
5 days. 
Death. 
Australian Med. 
Journ., July 15, 
1885, 303. 
First aspiration was done in 6th left interspace ; 
second in 4th right interspace; in third and 
fourth aspirations no information as to point 
is given; fifth tapping done in 3d left inter- 
space; incision. At autopsy a sinus found in 
2d interspace leading from pericardium to the 
subcutaneous tissue. This was nature’s effort 
to obtain a spontaneous opening for the pus. 
Author suggests to us that it may give a hint 
as to best point for tapping. 
Yes, with 
drainage 
tube. 
18 hrs. 
Death. 
Annals of Surg., 
Nov. 1885, quoted 
from Lond. Med. 
Record, Aug. 15, 
1885, from native 
journal. 
Autopsy showed cardiac dilatation with fatty 
degeneration, pleural and bronchial disease, 
and kidney lesions. Bacteriological examina- 
tion of heart and pericardium was negative. 
Original in Med. Oboz.. Moscow, 1885. xxiii. 
475. 
Yes, by 
Not 
Recov- 
Wiener med. 
Small fistule remained when case reported. 
stitching 
peri car- 
given. 
ery. 
Wochen.,Nov. 22, 
1884,1403. 
dium to 
edges of 
wound. 18 
ROBERTS: SUPPURATIVE PERICARDITIS, 
No. 
Operator 
and date. 
Sex 
and 
age. 
Dura- 
tion of 
illness. 
Complica- 
tion. 
Tapped pre- 
viously. 
Situation of 
incision. 
Quantity 
of pus 
evacu- 
ated. 
Irriga- 
tion. 
12 
Rouse 
(Dickinson’s 
patient), 
1887 
M. 
10 
About 
15 wks. 
Gluteal ab- 
scess, pleu- 
ritis; abscess 
of finger; 
pleura tapped 
12 times, ser- 
um obtained. 
Yes, three 
times; last 
time one 
week previ- 
ously. 
5th inter- 
space right 
side close to 
sternum. 
Not 
given. 
No. 
13 
Underhill, 
1887 
F. 
6 
2 days. 
Pyaemia; had 
periosteal ab- 
scess of tibia 
a few weeks 
previously ; 
autopsy; 
abscesses in 
kidneys and 
pleura. 
Yes, aspirat’d 
twice, last 
time five days 
before in- 
cision. 
5th left inter- 
space close to 
border of 
sternum. 
Over 10 
fl oz. 
No. 
14 
Parker, 
1888 
F. 
9 
6%wks. 
Osteomyelitis 
of tibia and 
suppurative 
arthritis of 
knee. 
Yes, four days 
previously. 
4th inter- 
space along 
left border 
of sternum 
with resec- 
tion of one 
inch of 5th 
costal carti- 
lage. 
“ A large 
qu’ntity" 
floccul’nt 
pus and 
lymph. 
Yes. 
15 
Hals ted 
(reported 
by Osier), 
1890 
M. 
36 
Over 
3 wks 
Acute necro- 
sis of bones of 
nose; albumi- 
nuria ; con- 
gestion of 
right lung. 
No. 
4th inter- 
space mid- 
way between 
nipple and 
sternum. 
Over a 
quart. 
No. 
16 
Delorme, 
1890 
M. 
18 days. 
Double 
pleuritis; 
empyema; 
operation. 
No. 
4th inter- 
space a little 
outside of in- 
ternal mam- 
mary vessels. 
Few 
drops. 
No. 
17 
Davidson, 
1890 
M. 
6 
■ 
Over 
4 wks. 
Metatarsal 
necrosis; sub- 
periosteal ab- 
scess 8th rib 
right side; 
empyema; 
pneumonia. 
Empyema; 
operated 
upon previ- 
ously. 
No. 
5th inter- 
space. 
8 fl. oz. 
No. 
18 
Davidson, 
1890 
M. 
6% 
Nearly 
4 wks. 
No. 
4th inter- 
space 1 inch 
from left edge 
of sternum. 
Several 
fl. oz. 
No. 
19 
Teale, 
1890 
(Bronner’s 
patient) 
F. 
11 
34 dys. 
Influenza, 
pneumonia. 
Empyema 
operated on 
previously. 
No. 
4th inter- 
space 1 inch 
from left edge 
of sternum. 
Nearly 
2 pints. 
Yes, iodo- 
form and 
glycerin, 
solutions 
of boric 
acid and 
carbolic 
acid. 
20 
Deaver, 
1890 
M. 
21 
18 dys. 
Synovitis (?) 
of knee. 
Yes, aspira- 
tion one day 
previously. 
5th inter- 
space 3 in. 
from middle 
line. 
Not much 
but gxvij 
removed 
by aspira- 
tion day 
before. 
No. 
21 
Sievers, 
1892 
F. 
22 
5 wks 
Pleuro-pneu- 
monia, empy- 
ema fin 
both sides; 
nephritis. 
Yes, seven 
days previ- 
ously with 
trocar. 
3d inter- 
space 2 cm. 
to left of 
sternum. 
Great 
quantity. 
No. 
22 
Korte, 
1891 
F. 
7 
Osteomyelitis 
of both tibias. 
Yes. 
Resection of 
5th rib for 5 
centimetres. 
% litre. 
Lysol 
solution 
% per ct. ROBERTS: SUPPURATIVE PERICARDITIS. 
19 
i Perma- 
nent 
1 drainage 
after 
| incision. 
Time of 
after- 
treat- 
ment. 
Result. 
Reference. 
Remarks. 
Yes, with 
2%mos. 
Recov- 
Trans. Clin Soc. 
Case considered one of pyaemia. Patient lay on 
1 drainage 
i tube. 
ery. 
Lond., 1889, p. 48; 
mentioned also 
in Holmes’ 
Treatise on 
Surgery. 
face at times to encourage drainage. 
Yes, with 
drainage 
tube. 
5 days. 
Death. 
Edinburgh Hosp. 
Rep., 1896, iv. 200. 
Several hemorrhages from interior of pericar- 
dium. Autopsy showed that the bleeding 
probably came from granulation tissue, on 
inner surface of pericardium, probably the seat 
of septic emboli. 
Yes, 
Death 
Death. 
Trans Clin. Soc. 
Pus did not flow well; it was thick and contained 
stitched 
occur’d 
London, 1889, 
membraniform shreds; hence irrigation was 
pericar- 
dium to 
edge of 
wound. 
during 
irriga- 
tion im- 
medi- 
ateiy 
after in- 
cision. 
Death. 
xxii. 60. 
adopted. Operator believed death was caused 
by irrigating fluid collecting in pericardium,as 
opening in pericardium became plugged with 
lymph. Patient was pysemic. No special lesion 
found at autopsy, except pericardial changes. 
As opening in pericardium became plugged 
with lvmph pressure on heart proved fatal. 
Yes, with 
gauze 
plug. 
17 dys. 
Univ. Med. Mag., 
vi. 248. 
Great improvement after operation. Dr. Osier, 
who reports case, calls the pericarditis septic 
and attributes the fatal result to probable myo- 
carditis. No autopsy was made. 
No. 
Few 
mo- 
ments. 
Death. 
Revue de Chir., 
1895, xv. 1008. 
Patient died of asphyxia which had caused peri- 
cardial operation to be hurriedly undertaken. 
Autopsy showed front of heart adherent to peri- 
cardium, and about 500 grms. of sero-pus col- 
lected at base and sides of heart, and a great 
quantity of false membranes that could only 
have been removed by a large opening followed 
by washiug and direct extraction. The open- 
ing in 4th space was over the adherent region. 
Yes, with 
drainage 
tube. 
7 days. 
Death. 
Brit. Med. Journ., 
March 14, 1891, 
578. 
Autopsy showed no pericardial adhesions; pneu- 
monia. Case was considered septic. 
Yes, with 
Over 
Recov- 
Brit. Med. Journ., 
drainage 
tube. 
7 wks. 
ery: 
March 14, 1891, 
578. 
Yes, with 
drainage 
tube. 
26 dys. 
Death. 
Brit. Med. Journ., 
Feb 14, 1891, 
350. 
No autopsy made; but a probe passed into peri- 
cardium discovered no adhesions, though soft 
granulations were felt toward base of heart. 
Yes, rub- 
ber tube 
13 dys. 
Death. 
Univ. Med. Mag., 
1894, vi. 297. 
Autopsy showed much fibrinous exudate within 
pericardium. [Case of a septic nature most 
probably.—J. B. R.]. 
Yes. 
8 dys. 
Death. 
Zeitsch. fur klin. 
Med , 1893, 
xxiii. 26. 
Found bacilli in fluid. Autopsy showed acute 
nephritis, pleuro-pneumonia, pericardial adhei 
sions, and some change in heart muscle. Peri- 
carditis was of a septico-pyemic nature. Opera- 
tor chose 3d interspace because 4th and 5th 
spaces were verv narrow. 
Not 
given. 
12 dys. 
Death. 
Verhand. d. Berl. 
med. Gesellsch. 
(1892), 1893, 
xxiii. 2. 
Autopsy showed numerous foci of pus in fissures 
of cardiac muscle, in papillary muscle of mitral 
valve, and in kidneys; caseous mass in lung and 
evidences of pleuritis were found. - Pus evacu- 
ated contained staphylococci, streptococci, and 
bacilli. [Case evidently septic.—J. B. R ] 20 
ROBERTS: SUPPURATIVE PERICARDITIS. 
No. 
Operator 
and date. 
Sex 
and 
age. 
Dura- 
tion of 
illness 
Complica- 
tion. 
Tapped pre- 
viously. 
Situation of 
incision. 
Quantity 
of pus 
evacu- 
ated. 
Irriga- 
tion. 
23 
Eiselsberg, 
1894 
M. 
17 
Over 
4% mos. 
Wound by 
knife in reg’n 
of heart 
had healed; 
left pleuritis 
and pneu- 
monia fol- 
lowed third 
tapping. 
Yes, three 
times. 
Resection of 
4th cartilage. 
2 litres. 
Yes, sol. 
of salicy- 
lic acid, 
then 
iodoform 
and 
glycerin 
24 
Edwards, 
1892 (?) 
F. 
6 
Not 
given. 
Sacculated 
empyema; 
opera’n with 
resec. of ribs; 
mediastinitis 
—nephritis. 
No. 
iu. within 
and above 
position of 
apex beat. 
Six. 
No. 
25 
Jacobson 
F. 
14 
Not 
given. 
CEdema of 
lungs. 
Not given. 
5th inter- 
space right 
side a little 
outside of 
sternum. 
Sxlvj. 
Not 
given. 
26 
Gabszewiez, 
1892 
M. 
22 
1 mo. 
None. 
No 
Resection 5th 
costal car- 
tilage. 
Large 
quantity. 
Yes, boric 
acid sol. 
27 
Robinson, 
1893 
M. 
16 
20 days. 
Sore-throat; 
swelling of 
left wrist first 
symptom. 
Yes, aspira- 
tion one day 
previously. 
Resection of 
6th rib. 
2 quarts. 
No. 
28 
29 
Marsh 
Klefberg 
M. 
14 
M. 
19 
Not 
given. 
Not given. 
Influenza 
previously. 
Not given. 
Yes. aspira- 
tion 150 grms. 
pus. 
Below the 
nipple. 
4th inter- 
space. 
Not given 
1 litre 
pus. 
Not given 
30 
Bohm, 
1894 
M. 
33 
1 mo. 
Influenza 
previously ; 
pleuro-pneu- 
monia. 
Yes, three 
times. 
3d interspace. 
1 litre. 
Yes. 
boric acid 
solution. 
31 
Allen, 
1892 
M. 
11 
Not 
given. 
Empyema re- 
quiring costal 
resection one 
year before. 
Yes, aspira- 
tion. 
Resected 6th 
rib below 
and inside 
left nipple. 
2 quarts. 
Yes, with 
sterile 
water. 
32 
Stoker 
(O’Carroll’s 
patient), 
1892 
M. 
20 
34 days. 
Pneumonia; 
left pleural 
effusion sub- 
sequent to 
operation. 
Yes. aspira- 
tion five days 
previously. 
4th inter- 
space mid- 
way between 
nipple and 
sternum. 
Not given 
No. 
33 
Bjorkman 
F. 
About 
Influenza 
Yes, in 4th 
Resection 
400-500. 
Yes, 
(orHackzell), 
1895 (?) 
12 
3% wks 
and pleuro- 
pneumonia 
previously. 
interspace. 
5th and 6th 
ribs. 
c. c. 
boric acid 
solution. 
34 
Porter 
(Shattuck’s 
patient), 
1895 
M. 
26 
33 days. 
Pneumonia 
before peri- 
carditis ; 
empyema 
afterward 
requiring 
resection. 
Yes, aspira- 
tion two days 
previously. 
5th inter- 
space 1% in. 
to left of 
sternum. 
1 quart. 
Yes, with 
sterile 
salt 
solution. 
35 
Garber, 
1897 
F. 
21 
2 wks. 
Pericarditis 
caused by 
penetrating 
wound with 
steel crochet 
needle. 
Not tapped 
previously. 
5th inter- 
space 1% in. 
to left of 
sternum. 
About 1 
fl.oz.thick 
pus and 
also puro- 
sanguino- 
lent fluid. 
Yes; salt 
solution. ROBERTS: SUPPURATIVE PERICARDITIS. 
21 
Perma- 
nent 
drainage 
after 
incision. 
Time of 
after- 
treat- 
ment. 
Result. 
Reference. 
Remarks. 
Yes, two 
About 
Recov- 
Wein.klin.Woch., 
Drains kept in pericardium for seventeen days. 
tubes. 
6 wks. 
ery. 
Jan. 10,1895, p.21. 
Yes, rub- 
Not 
Death. 
Trans. Med. Soc. 
Began as mediastino-pericarditis with secondary 
ber tube. 
given. 
of State of Cali- 
fornia, 1893, 166. 
pleurisy; at least this was the belief of Ed- 
wards after an autopsy. 
Not 
given. 
Not 
given. 
Death. 
Jacobson’s opera- 
tions of Surgery, 
Lond., 1897, 590. 
Death occurred from oedema of lungs. 
Yes, by 
Not 
Recov- 
Gaz. Leklarsk, 
iodoform 
gauze for 
given. 
ery. 
Warsaw, 1892, 
2 ser. 12, 1070. 
18 days. 
Drainage 
About 
Recov- 
Lancet, Nov. 21, 
tube. 
2 mos. 
ery. 
1896, p. 1460. 
No. 
4 days. 
Death. 
Lancet, Nov. 21, 
1896, p. 1460. 
6 days. 
Death. 
Tidskrift i Mili- 
tar. Helsovord, 
17 Arg. 1892, 
Stockholm, from 
Shattuck and 
Porter. Boston 
Med. and Surg. 
Journ., May 6, 
1897, p. 444. 
Autopsy showed pus in right ankle-joint and 
right sterno-clavicular joint. 
[Probably septic.—J. B. R.] 
Gauze 
3 mos. 
Recov- 
Deutsche med. 
Schleich’s infiltration method of local anaesthesia 
drain. 
ery. 
Wochen., Nov.26, 
1896, p. 769. 
was used. Out of bed in four and a half weeks. 
Wound closed in three weeks; well a year 
later. 
Gauze 
drain. 
20 days. 
Death. 
Personal com- 
munication from 
Dr. D. P. Allen, 
Cleveland, Ohio. 
Drainage 
tube in- 
serted on 
30 days. 
Death. 
Dublin Journ. 
Med. Sciences, 
July, 1896, p. 11. 
Frankel’s diplococcus found in pus. 
3d day. 
Yes, two 
6 weeks 
Recov- 
Hygeia, Stock- 
Pleural cavity was opened during resection and 
large 
drainage 
ery. 
holm, lviii. pt. 2, 
p. 189, 1896. 
some serum evacuated. The pleural opening 
was then sutured. 
tubes. 
Pneumococcus in pus ; pneumothorax and em- 
pyema occurred after pericardotomy; then 
Two 
On 36th 
Recov- 
Boston Med. and 
rubber 
dav 
ery 
Surg. Journ., 
tubes. 
wound 
entirely 
healed; 
empy- 
ema ; 
sinus 
finally 
closed 
in 
about 
10 mos. 
May 6, 1897, 
p. 438. 
erysipelas of back and shoulder. Pneumococ- 
cus in pus from pleural sac. 
Yes, with 
gauze. 
24 days. 
Recov- 
ery. 
Journ. Amer. 
Med. Assoc., 
June 26,1897, 
p. 1223. 22 
ROBERTS: SUPPURATIVE PERICARDITIS. 
the pericardium. The pericardial sac is incised vertically or obliquely 
between the sternal border and the displaced vessels and pleura and a 
drainage-tube inserted. The length of the incision into the pericardium 
should be sufficient to permit extraction of membranes and thick pus. 
The surgeon’s finger may be introduced for exploration. 
If irrigation is employed, it is best to use two tubes, one to admit the 
fluid, the other to give it free exit. The drainage-tubes are introduced 
and brought to the surface through the fifth intercostal space, after 
trimming away the lower portion of the flap; and the chondro-plastic 
flap laid in position. If it is preferred, the tubes may be brought out 
through holes made in the flap between the fourth and fifth cartilages. 
The bevelled cartilages fit accurately together, and the flap will show 
little tendency to drop inward, even if the lungs and pericardium fail 
to support it. The cartilages may be sutured with catgut by passing 
the needle through their substance. In cutting the cartilages obliquely 
during the early part of the operation it is desirable not to bevel them 
too much, because the internal edges then project so far that it is diffi- 
cult to get under the sternum. The bevelled surface should make an 
angle of about 45° with the internal surface of the cartilage. 
It may be objected that this method of resecting the thoracic cage 
does not open the pericardium at its very bottom. It might be sug- 
gested to resect the fifth and sixth cartilages instead of the fourth and 
fifth. I prefer not to do this, because there is considerable danger 
of opening the abdomen when separating the outer end of the sixth 
cartilage from the underlying tissues. This danger would be less, of 
course, if a pericardial effusion had pushed the diaphragm downward. 
The manner in which the outer portion of the costal cartilage of the 
sixth rib runs obliquely downward renders the danger more imminent 
than might be supposed. Another objection to resecting the sixth 
cartilage is the common presence of a cartilaginous bridge between 
the sixth and seventh costal cartilages. This would complicate a little, 
though not to a great extent, the lifting up of the trap-door. Such a 
bridge sometimes occurs between the fifth and sixth cartilages. 
Operators who have made similar resections of the chest-wall in 
operations for suppurative pleuritis have proved by skiagraphy that 
consolidation takes place if the perichondrium be retained. Restora- 
tion would certainly be much more probable in the operation which is 
here advocated, since not only the perichondrium but the cartilages 
themselves, with many of their connections, have been retained. 
The evacuation of the fluid after opening the pericardium can be 
made complete at times by a change in the posture of the patient or 
breaking down adhesions by a probe or the finger introduced into the 
sac. It does not seem to be especially dangerous to allow the pus to 
flow out rapidly, but it is wise to permit the escape to be gradual. ROBERTS: SUPPURATIVE PERICARDITIS. 
Aspiration can be readily done under local anaesthesia by cocaine or 
freezing. Resection in the manner advocated will probably require 
general anaesthesia. If the severity of the symptoms renders general 
anaesthesia dangerous, it may be well to withdraw a portion of the fluid 
by the aspirator needle used for diagnosis in the xiphoid fossa, and delay 
drainage by incision and resection until the patient’s condition will per- 
mit the administration of an anaesthetic. The patient should be allowed 
to remain recumbent or semi-recumbent during the operation. The 
tubes should be prevented from slipping into the pericardium by being 
stitched to the skin or having a safety-pin thrust through their outer 
ends. 
Operations upon the pericardium for pyopericardium would seem, on 
general principles, to promise better results in a mechanical way than 
similar operations upon the pleura, for the pericardium is elastic and 
more easily drained than the pleura. If it becomes thickened and does 
not collapse after evacuation of pus, I would be inclined to incise any 
remaining fistule and cut away the thickened pericardial tissue. 
Pericardial fistules should be treated as fistules elsewhere. After 
sufficient time has been given to make it clear that spontaneous healing 
will not occur, the fistule should be laid open and thickened tissue 
removed. The Medical News. 
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