A CASE OF HÆMOPERICARDIUM OF TRAUMATIC ORIGIN; OPERATION
THE patient, a girl, aged 2 years and 7 months, was brought to the East London Hospital for Children on Dec. 11th, 1911. The child had been seedy for several weeks, and three days before admission had fallen over a chair and had since complained of pain in the front of the chest and in the stomach. The parents discovered no evidence of injury and the child's general condition was not appreciably affected by the accident. Two days after the fall the broken half of a needle was found in the
... found in the child's corset. The patient walked to the hospital, and while in the casualty room was seized with a syncopal attack and admitted at once to a medical ward under the care ot Dr. H. Morley Fletcher. The patient responded to stimulation and regained consciousness. The condition on examination was as follows. Pulse almost imperceptible at the wrist, respirations normal, and temperature 96° F. The patient was very pale, the eyes T being sunken, and she looked extremely ill. Examination of s the abdomen and lungs revealed nothing abnormal. There f, were no nervous symptoms. The apex beat could not be d felt. Cardiac dulness extended one finger's breadth to the s1 right of the sternum, to the second interspace above, and to s the left as far as the nipple line. The heart's rhythm was f tic-tac, the action irregular, and the sounds extremely feeble. I Faint double pericardial friction was present at the lower end of the sternum, extending outwards into the fourth, b fifth, and sixth spaces on the right side, with maximum s intensity in the fourth space three-quarters of an inch to the s right side of the lateral sternal margin, where a small scar C of the size of a pin's head was present. Blood examination Y revealed a leucocytosis of 28,500 per c.mm.; polymorphs 90 1 per cent. A diagnosis of pericarditis with effusion was made. The patient gradually relapsed into the condition in which she was seen on admission, and as stimulants were of no avail paracentesis pericardii was performed, the exploring needle being passed through the fifth intercostal space t 1 inch to the left of the sternum. 20 c.c. of thick bloodstained fluid were withdrawn. The pulse at once returned at the wrist, the heart sounds became louder, and marked ' pericardial friction was to be heard over the whole of the prsecordia, with maximum intensity in the fourth right interpace. The child immediately regained consciousness, sat up in bed, and asked for her mother. Shortly afterwards she fell asleep and remained quiet for several hours. Six hours after the operation the patient became restless, pulse feeble and irregular, and an hour later was completely unconscious, the physical signs present being identical with those before paracentesis was performed. Paracentesis was repeated, with precisely similar result, only 5 c.c. of fluid, however, being obtained. On examination the fluid was Tnl1nil tn onfiralw nf hlnnr3 wnin-h hnwovnr ahnwori no signs of clotting after-standing for several days. Cultures were sterile. The question of the cause of the condition was now to be considered. Having regard to the fact that a portion of a -needle was removed from the clothing of the patient at a point corresponding to the skin wound on the chest, where the pericardial friction reached its maximum intensity, the origin of the effusion was considered to be traumatic. This was confirmed by X ray examination of the chest made six days later, the child having steadily improved meanwhile. 'The radiogram clearly showed what exactly corresponded to the undiscovered fragment of the needle embedded in the <ihest wall to the right of the sternum. It was decided to remove it and the operation was performed the following day by Mr. Wilfred Trotter. The anassthetic used was intravenous ether, 5 per cent. in Lormal saline, at room temperature. The cannula waa nserted into one of the veins at the bend of the elbow. Lnsesthesia was induced in five minutes and remained com-)lete and even throughout the operation, the patient's condition causing no anxiety. Twenty-two ounces of solution vere used. The operation lasted 55 minutes. A rectangular skin flap was raised, beginning 1 inch external to the junction of the tecond costal cartilage with the rib on' the left side, pro-.onged inwards to the midsternum, then downwards for about 3 inches, and finally outwards to a corresponding point on the fifth rib, exposing the second, third, and fourth costal cartilages ; these were removed. In the exposure of the pericardium the right pleura was accidentally opened and sewn up with catgut. A small incision was made into the pericardium at the level of the third intercostal space and 300 c.c. of blood-stained fluid were allowed to escape. The incision was then enlarged, and with the finger the sharp needle-point was felt passing oneeighth of an inch into the pericardium, the bulk of the needle being firmly fixed in the chest wall at the level of the fourth intercostal space on the right side, one inch from the sternum. The needle point was embedded in firm inflammatory exudate. This was broken down to give free access to the foreign body, which was removed with considerable difficulty by means of a pair of curved forceps and delivered by way of the pericardium. The skin flap was sewn up, and a cigarette drain inserted into the pericardium. For six days the patient's condition remained satisfactory ; there was a slight pneumothorax, which quickly subsided. The discharge was now sero-purulent, and in the course of the snncp.ffHnc' fAw data bfffimf* niirnlplnt-which in view of thf fact that an infective condition of the pericardium was demonstrated at the operation was not surprising. The streptococcus pyogenes and a diphtheroid organism were cultivated from the pus. Broncho-pneumonia set in on the fourteenth day, and proved fatal a fortnight later. The wound up to the end was satisfactory. Necropsy.—Post-mortem examination revealed extensive broncho-pneumonia. The heart was greatly increased in size, chiefly due to hypertrophy of the left ventricle, the wall of which measured half an inch in thickness. Endocarditis of the mitral valve was present ; the other valves appeared healthy. Dense adhesions were present between the two layers of the pericardium. These were most notable low down on the anterior surface, and especially on the posterior surface of the right ventricle towards the apex. The density of the adhesions prevented the demonstration of any small traumatic lesion, while there was no evidence of an extensive wound of the pericardium or the heart wall. The left t ventricle was covered with a more recent buttery exudate. Adhesions were present over the roots of the great vessels posteriorly. Posteriorly over the right ventricle the pericardium was one-fifth of an inch thick. The haemorrhage must have been due to wounding of the parietal pericardium by the needle; the fact that paracentesis had to be repeated would suggest that oozing was still going on when the child was admitted to hospital. It is interesting to note how comparatively comfortable the patient remained up to the time of the operation considering the size of the effusion that was demonstrated on opening the pericardium. This can be best explained by the absolute rest and quietness , that were enforced. , Haemopericardium in children would appear to be a rare I condition, as records of two cases only can be found in English and American literature. One, a case of sudden death in a child aged 5, is reported by Evans. Post mortem the pericardium was found to be distended with blood, the haemorrhage resulting from rupture of an aneurysm of the left coronary artery. The other, recorded by Morse,2 occurring in a girl aged 2-2L years, is an almost parallel case with the present one. In it, however, the symptoms were slow in onset and milder in character, recovery resulting after one aspiration of 400 c.c. of fluid. The fragment of the ' needle remained in the body, operation being refused. 3 I am greatly indebted to Dr. Morley Fletcher, under whose e care the case was, and to Mr. Trotter, who performed the r operation, for permission to publish these notes.