PERICARDITIS

A patient suffering from acute pericarditis, whatever the aetiology, should be nursed at complete rest in bed. For those with acute rheumatic carditis, the general lines of treatment are as described under that heading. In tuberculous cases the general measures are those appropriate to tuberculosis and streptomycin, isoniazid and PAS should be given in appropriate doses. Cases which occur in association with pyogenic infections (haemolytic streptococci, staphylococci, pneumococci, etc.) are treated with the appropriate antibiotic, the possibility of the development of a purulent effusion being kept in mind. The so called benign non-specific variety generally clears up rapidly without specific treatment and without residual disability. Peri¬carditis occurring in the course of disseminated lupus erythematosus responds, like the other manifestations of this protean disorder, to treatment with corticosteroids.
The relief of pain may call for treatment, though many patients suffer surprisingly little discomfort even in the presence of a loud friction rub. Mild analgesics such as acetylsalicyclic acid, or compound codeine tablets may suffice, but severe pain may necessitate the administration of 15 mg. of morphine with the customary proviso regarding its dangers in young children. Counter-irritation and the traditional ice bag have passed into disuse, relief from pain being more easily attained by analgesics.
A large effusion may embarrass the heart's action or interfere with respiration by causing partial collapse of the left lung. It is unusual for such symptoms to be severe enough to warrant aspiration of the pericardial effusion, but tapping must be carried out promptly with the appearance of the signs of tamponade— rising venous pressure and pulse rate, onset of cyanosis, increasing dyspnoea and general distress. Aspiration is also a routine diagnostic procedure when bacterio¬logical examination of the fluid is necessary, or when the presence of pus has to be excluded. For diagnosis the aspiration of a few millilitres of fluid will suffice, but to relieve tamponade the aspiration of several hundred millilitres may be necessary. The technique of paracentesis is described on p. 922. With malig¬nant involvement of the pericardium, rapid re-accumulation of effusion after paracentesis is common ; for this, local radiotherapy may be given by instilling into the sac a radioactive isotope of gold. This is done under the guidance of a radiotherapist, familiar with dosage requirements, isotope hazards to personnel, etc., and is at best palliative.
Pus in the pericardial sac is an indication for surgery. Drainage may be established by open operation, with resection of ribs, or by a closed method, by insertion of a tube through the soft tissue of an interspace and the maintenance of suction. Both methods yield good results, and the choice must lie with the surgeon. Suitable antibiotics should be used systemically and locally.
In non-purulent cases recovery with absorption of the effusion is the rule, except in the terminal acute pericarditis which occurs in the last stages of Bright's disease and other cachectic conditions. Convalescence may be slow, and there is no efficient method of hastening absorption of the fluid. Repeated assessment of the size of the effusion and of the patient's general state will guide the physician in his decision as to when to allow the patient to move about in bed, when to allow him up, etc. Patients on recovery from the acute attack may be allowed a fair amount of exercise, but should be re-examined from time to time during the ensuing years to detect the development of other lesions or of chronic constrictive pericarditis. When pericarditis occurs as part of a polyserositis, joint supervision by physician and thoracic surgeon is desirable, for operation may be indicated at a stage before hard scar tissue or calcined deposits have formed.