1905 The Lancet  
157 ofyears invariably adopted in cases of this nature I examined the pericardial region. The heart sounds were faintly audible and the pericardial dulness, or rather flatness, was markedly increased upwards and also extended to the right of the sternum. I strongly suspected that this was due to an accumulation of pus and the diagnosis being confirmed. by means of an exploring syringe I at once opened the pericardium by making an incision in the fourth left intercostal space, three-quarters of
more » ... three-quarters of an inch from the margin of the sternum. With dressing forceps the incision was enlarged and a quantity of greenish-yellow pus escaped. A drainage-tube was inserted. At the completion of these operations, which were all done at one time, the boy's condition was extremely grave. He.rallied, however, in the course of a few hours and after a prolonged convalescence made a very satisfactory recovery. In the after-treatment of the case the chief difficulty we had was in connexion with the imperfect drainage of the pericardial sac. The incision made for this purpose was directly over the heart, with which the drainage-tube came in contact, and I firmly believe the boy's ultimate recovery was largely due to the care and attention bestowed upon him by my house surgeon, Mr. T. St. John Barry, who twice daily for several weeks passed a catheter through the wound and round to the back of the heart and then by means of a small glass syringe attached to the catheter washed out the pericardial cavity. The wounds of the ankle and toe healed long before the pericardial wound which finally closed on Nov. 1st, having discharged for nearly three months. The boy left the hospital on Nov. 10th and apart from a little lameness is in excellent health. Though I have several times operated for suppurative pericarditis this is my one successful case. I would draw attention to what I believe to be an important clinical fact-namely, the not infrequent association of suppurative pericarditis with acute osteomyelitis. Why in such cases the pericardium should become involved I do not know but I have so frequently met with this complication that I now invariably examine for it and the sign I place most reliance upon is increased cardiac dulness. Another point of interest is how best to drain the pericardial cavity, for in this class of case if there is increased pericardial effusion it is almost certainly purulent and, if circumstances permit of it, should be evacuated. A number of different methods of operating have from time to time been suggested, many of them too elaborate and extensive to be of any practical value for in dealing with a case of suppurative pericarditis one is dealing with an acute abscess in a very ill person and whatever is done in the way of an operation must be done quickly. As the opening must be made from the front it is impossible to obtain dependent drainage so long as the patient lies on the back; but if the opening is made in the costo-xiphoid space, as suggested by the late Mr. Herbert W. Allingham, together with removal of a portion of the seventh costal cartilage if considered necessary, as recommended by Mr. Herbert S. Pendlebury, then with the patient propped up in bed we have the most dependent opening for drainage that can be obtained. If for any reason the drainage should not be satisfactorily maintained, I would not hesitate to employ gentle irrigation as was so successfully done in the case to which I have referred. Liverpool. IT but rarely happens that amongst the enormous amount of medical literature published at home and abroad the searcher has any difficulty in finding reports on cases similar to his own. But the condition in question must be a rare one, for after a most diligent seeking in all the sources available to me I have found but one other case of the above disease. That one was reported by Professor Hearn of Philadelphia in the Annals of Surgery for 1897 and in describing it the author makes the remark that he has found no note of any similar case. On this account alone I think the following details are worth recording at length, but the unexpectedly successful termination of the case has, I confess, given me a stronger reason for making a report. The patient, a girl, aged nine and a half years, although looking younger, was brought to see me on account of a swelling in her body. She was a child with a sallow, rather pasty complexion and small for her years. Her mother had noticed the body decidedly swollen and large for more than a year previously and had taken her about that time to see a medical man who pronounced it "consumption of the bowels." The mother thought the child was always full and prominent in the body from infancy. No pain was complained of nor apparently discomfort; child-like, she accommodated herself to her condition. She was easily tired and readilv out of breath although she could sleep without propping-up. She was much emaciated in the chest, the arms, and the legs. She had attended school up to three months previously and even now ran about and played. Appetite and digestion were good and the bowels were regular. On examination the body was seen to be enormously distended and nearly uniformly so but probably more in the epigastric region. Distended veins were marked on its surface ; the lower ribs were bulged outwards. The body was firm and elastic ; there was no hardness or rigidity anywhere. There was complete dulness to percussion all over-not a resonant note anywhere. Turning her on either side made no difference, nor in the erect position was there anything but a dull note in the epigastrium. Fluctuation was evident and a very decided thrill-wave made it certain that it was fluid. I was puzzled how to reconcile these facts but decided that the peritoneal cavity was so completely full as to explain them-an erroneous conclusion. As the child's breathing was becoming more embarrassed an operation was advised. I could think of nothing more likely than tuberculous peritonitis and so informed the mother that draining away the fluid might probably cure and would certainly relieve the condition. The temperature was normal and the urine contained no albumin. The lungs were crowded up and the heart was displaced upwards and outwards beyond the nipple line. A small incision being made in the middle line and the peritoneum opened, a bit of what appeared like gangrenous bowel protruded through, but no fluid came. Prolonging the incision upwards to the umbilicus and downwards to near the pubes I made clear by putting in my fingers that I had a cystic condition to deal with and evidently multilocular. I tried tapping, but the cyst wall was so thin and offered so little resistance that there was no success. I therefore incised and a gush of dark brown fluid, evidently brokendown blood and serum, followed. As this emptied but one loculus I required to treat the others within reach in the same way. After relieving the cavity of a large quantity of fluid I could insert my whole hand and feel the extent of the tumour. I found that it extended to the stomach, beginning near the pylorus and reaching round the great curvature to the cardiac end, and from there right across to the spleen, the gastro-splenic omentum consisting of one large loculus. The child became very ill under the ether and as the ansesthetist (Dr. S. Clark) gave a very bad account of the pulse and the task of removing the whole was a very formidable one I thought it better to tie off what there was of collapsed cyst wall about two inches above the level of the umbilicus. This I did in the usual way as if dealing with normal omentum, for omentum it clearly was, and, in fact, by dragging upwards the wound Mr. J. J. Anning, who assisted me, and I had a good view of the stomach with the dark-purple e cysts bordering and overlapping it intimately around. A good deal of mopping out was required to be done in the pelvis where the organs were quite normal. In making the toilet of the cavity before closing I found a bit of healthy omentum running up to the transverse colon, so that evidently the cysts involved only the anterior layers of the great omentum. The fluid that was caught measured 32 pints but five or six pints more at least must have run to the floor, much to our discomfort. The fluid and cyst wall were unfortunately not examined. The little patient was much collapsed after the operation but soon rallied with the help of strychnine and saline injections and three or four hours later was quite bright and cheerful. She complained so much of thirst that I allowed her then half a pint of weak tea and milk. During the first seven days she did well, the pulse was good, the temperature was normal, and nutriment was taken fairly. Some ounces of fluid were drawn off daily for the first few days and a lessening quantity during the next few days through the Bantock's tube left in to drain the pelvis. A rubber tube was substituted for the glass one at the end of a week but this
doi:10.1016/s0140-6736(00)94724-x fatcat:jb2wekmgzbdzjlp2yyvhyzo2qu