388 



PERICARDITIS. 



The right index finger is then replaced, by the left, and, a trocar about 

 10 inches long and ^ inch in diameter being introduced along the index 

 finger used as a director, the pericardial sac is reached. The exudative 

 fluid transmits the impulse due to the beating of the heart, and the 

 pulsations can be clearly distinguished when grasping the handle of 

 the trocar. 



Third stage. Digital exploration of the course of the puncture and 

 fatty cushion at the base of the heart, with the object of discovering the 

 position of the j^ericardium. 



Fourth stage. Puncture with a trocar about 10 to 12 inches in 

 length, puncture of the pericardium, irrigation and dressing. 



The trocar is inclined in a slightly oblique direction from without 



Fig. 179. — Photograph of a patient hnmediately after operation, 

 oedema of the dewlap and neck. 



Extensive 



inwards and forwards towards the median plane, in order that the point 

 may not deviate towards the left pleural sac ; the left index finger is then 

 withdrawn, and by a sharp thrust of the right hand the trocar is pushed 

 forward about 1 to IJ inches and the pericardial sac is entered. 



The position of the canula should not be altered whilst liquid is 

 escaping, for if it is thrust in too far a considerable quantity of fluid 

 may remain in the deepest portion of the sac. 



The cavity having been drained, a long strip of iodoform gauze is intro- 

 duced into the track and a protective surgical dressing applied over the 

 incision in order to prevent infection by the litter. 



In consequence of the introduction of the fingers into the track caused 

 by puncture and the escape of pericardial liquid along the canula or after 

 removal of the canula, the operative wound is necessarily infected ; but this 



