Pericardium . 133 



will be again referred to, when speaking of "tracheal tug- 

 ging" in the diagnosis of aortic aneurism. 



In Pericarditis with Effusion the fluid in the 

 sac causes a muffling of the sounds of the heart and an in- 

 crease in the area of cardiac dullness. In dilitation of 

 the heart the sounds are also muffled or weakened and the 

 area of dullness is increased, but, in these two conditions, 

 i.e., pericarditis with effusion and dilitation of the heart, 

 the shape of the dullness differs, since, in the former, it is 

 triangular in shape, with the apex upwards and the base 

 downwards (agreeing with the outline of the pericardium 

 itself) , whereas, in the latter, i.e., in dilitation, the area of 

 dullness will depend on the particular cavity of the heart 

 affected. ' ' 



A sign of some importance in pericarditis with effu- 

 sion is Bamberger's sign. This consists in an area of dull- 

 ness about the size of a silver dollar, situated at the in- 

 ferior angle of the left scapula and over which, increased 

 fremitus and bronchial breathing are evident. This area 

 disappears if the patient bends forward, to reappear when 

 he assumes the upright position. 



Operations. TV> aspirate in pericarditis with ef- 

 fusion, the needle should be inserted in the fifth left inter- 

 space, about two inches from the sternum, so as to avoid 

 the left internal mammary artery, but, when pus is pre- 

 sent in the pericardial sac, instead of withdrawing it by as- 

 piration, an incision may be made for the purpose of evacu- 

 ating it. The steps in this operation of draining the sac in 

 suppurative pericarditis, as advised by Porter, of Boston, 

 are as follows : An incision is made from the middle of the 

 sternum outwards along the fifth left costal cartilage as 

 far as its junction with the rib. The soft parts are clean- 

 ed from the rib with a periosteal elevator, the cartilage is 

 divided and removed, the internal mammary artery is ex- 



