PERICARDITIS IN THE DOc;. 169 



When, despite treatment, the exudate increases and the symptoms 

 become more marked and alarming, or when even on first examination 

 the general condition appears dangerous, I puncture the pericardium. 



Operation is as follows : — The precordial region is prepared by 

 clipping away the hair, and shaving the skin a little below the centre of 

 the zone of dulness for a distance of two or three square inches. The 

 parts are afterwards washed with alcohol, and with a 'i per cent, solu- 

 tion of sublimate. I prefer an aspirator provided wdth an india-rubber 

 tube, and I proceed as you saw in the case of our last patient. The 

 air being exhausted from the cylinder of the aspirator, the instrument 

 is passed to an assistant ; I introduce the point of the needle at the 

 centre of the prepared surface, through the fifth intercostal space three 

 or four fingers' breadth above the lower margin of the thorax. As soon 

 as its end has fairly entered the thoracic wall I open the tap connected 

 with the aspirator ; then I very gently push forward the needle until 

 liquid appears in the glass index of the rubber tube. Operating in this 

 way the needle need only just enter the pericardium, and with a short 

 point, injury of the heart (which is always pushed upwards and shortened 

 in its vertical axis) need not be feared. Furthermore, by using a small 

 needle, fluid is very slowly withdrawn and danger of syncope prevented. 

 In the absence of an aspirator, puncture may be effected with a fine 

 trocar. After operation the wound is closed by painting with collodion, 

 and the parts covered with a cotton-w'ool dressing. 



Should the exudate again form, reproducing the symptoms, operation 

 must be repeated. To prevent further recurrence in such a case, a few 

 drachms of very dilute iodine solution or some other antiseptic liquid 

 may be injected into the pericardial sac after removing the exudate. 



During the following days the patient is fed on milk, milk prepara- 

 tions, meat juice, or fragments of raw meat. When appetite returns, 

 more substantial food and tonics may be given. 



When pericarditis is complicated with ascites I generally remove 

 the peritoneal fluid by tapping the abdomen, but this is not always 

 necessary. Once the pericardium is relieved, the peritoneal exudate 

 tends naturally to become absorbed. Its disappearance is assisted by 

 administration of diuretics. 



The reason why treatment so generally fails is that, in the majority 

 of cases, pericarditis is produced by tuberculosis. In such case, puncture, 

 whether or not followed by iodine injections, can only produce tem- 

 porary improvement. Even when tuberculosis is exclusively confined 

 to the pericardium (I have seen a case of this kind) the liquid is repro- 

 duced, and the patient dies from complications of pericarditis, or from 

 progressive emaciation. 



