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15 J unie 1963 S.A. TYDSKRIF VIR GENEESKUNDE 637

be stated categorically that UML-491 was solely responsi­ for further investigation and double-blind trials are sug­ ble for the apparently good result, because migraine-type gested. headaches are subject to a number of aetiological factors I wish to express my thanks to Dr. P. G. Stein of Sandoz and trigger mechanisms. The paper has been presented for his cooperation in supplying articles and other literature, as a suggestion of how the headache-mechanism cycle as well as for supplying deseril for this trial. might conceivably be broken if the hypothesis that sero­ tonin is responsible for a number of vascular headaches REFERENCES

is acceptable. 1. Graham. J. R. and Wolff. H. G. (1937): Res. Pub!. Assoc. erv. Furthermore, that serotonin antagonism is desirable Ment. Dis.• 181. 63 . in the therapeutic approach to vascular headaches re­ 2. Wolff. H. G .• Tunis. M. M. and GOOell. H. (1953): Arch. Intern. 3. ~s~~i/~. iZt.: Chapman. R. F .• Godell. H. and·Wolff. H. G. (1957): quires further investigation, as does the 5-HT-headache Psychosom. Med.. 19. 199. relationship. 4. Graham. J. R. (1960): 'ew Eng!. J. Med.• 263. 273. 5. MacGregor. J. MacW. (1963): S. Afr. Med. J .• 37. 168. 6. (a) Wolff. H. G. (1955): Int. Arch. Allergy. 7. 4. SUMMARY (b) Idem (1948): Headache and other Head PaillS. ch. 11. London: Oxford University Press. 1. A short survey of migraine-type vascular headaches 7. Brodie. B. B. et aJ. (1958): Postgrad. Med., 24. 296. 8. Hess. W. R. (1958): Op. cit'. p. 296. is presented. 9. Franchamp. A .• Doepfner. W .. Weidmann. H. and Cerletti. A. (1960): Schweiz. med. Wschr.. 90. 1040. 2. The question whether serotonin is a neuro-humoral 10. Cerletti. A. and Doepfner. W. (1958): Helv. physio!. pharmacal. Acta. 16. C55. aetiological agent is discussed. 11. Sicuteri. F. (1959): Int. Arch. Allergy. 15. 300. 12. Heyck. H. (1960): Schweiz. med. Wschr.• 90. 203. 3. The pharmacodynamics of serotonin are enumerated. 13. Friedman. A. P. (1960): J. Angio!.. 11. 364. 14. Dalsgaard. ielsen. T. (1960): Praxis. 49. 867. 4. The chemistry and pharmacological actions of a sero­ 15. Harris. M. C. (1961): Ann. Allergy. 19. 500. tonin antagonist, methysergide, are listed. 16. Rooke. E. D .• Rushton. J. G. and Peters. G. A. (1962): Proc. Mayo Clin.. 37. 433. 17. Abbott. K. H. (1962): Dis. erv. Sys!.. 23. 579. 5. Five pilot trial cases treated with methysergide 18. Graham. J. R. (1960): New Eng!. J. Med.. 263. 1273. (UML-491 , deseril) are reported. 19. Friedman. A. P. and Losin. S. (1961): Arch. euro!. (Chic.). 4. 241. 20. Hale. A. R. and Reed. A. F. (1962): Amer. J. Med. Sci .• 243. 146. 6. A suggestion that serotonin antagonism may be use­ 2!. Ekbom. K. A. (1962): Acta psychiat. scand.. 38. 313. 22. Tucker. R. B. K. and Yodaiken. R. E. (1963): S. Afr. Med.• J .• 37. ful in breaking the headache cycle is made, and reasons 555.

PERICARDIAL ASPIRATION WITH A NEEDLE ELECTRODE DAVID JAcoBSO , M.B. (CAPE TOWN), D.C.H. (ENG.), M.R.C.P. (EorN.), Registrar. Department of Medicine, University of Cape Town, and Cardiac Clinic, Groote Schuur Hospital, Cape Town*

Aspiration of the pericardial sac is a procedure which induces far more anxiety and discomfort in the operator than in the patient. It is a 'blind' procedure not without risk and, though no figures of the mortality attendant on its use are available, fatal accidents do occur.' The risk is particularly high when pericardiocentesis is employed to differentiate pericardial effusion from cardiac failure of unknown origin (cardiomyopathy). In most instances pericardial effusion can be differentiated from cardiomyo­ pathy on clinical grounds. However, in the occasional patient the diagnosis can only be made by aspiration; advancing a needle into a pulsating myocardium can be a dangerous and nerve-racking manoeuvre. In this country both pericardial effusion and cardio­ myopathy of unknown origin are extremely common con­ ditions. In a recent series of 160 cases of pericarditis, pericardial effusion was present in 100.' The purpose of this communication is to draw attention to a safe tech­ nique for pericardial aspiration. Bishop et al.' in 1956 reported a method based on con­ 1 tinuous electrocardiographic (ECG) monitoring during the procedure. A slight modification using a pericardiocen­ Fig. 1. The chest lead of the ECG is plugged into the tesis electrode has been described' and this technique is brass socket (A). An insulated flexible copper wire (B) the one discussed here. A simpler needle has since been connects the chest lead to a brass collar with a screw designed.' The pericardiocentesis electrode (Fig. 1) con- (C), which serves as an electrical contact with the needle shaft (D) as well as an adjustable depth guard. A two-way * From the Cardiac Clinic, and CSIR Cardio-pulmonary tap (E) facilitates aspiration and expulsion of pericardial Group, University of Cape Town. fluid. 638 S.A. MEDICAL JOURNAL 15 June 1963 sists of a brass socket (A) to which an ECG chest lead _ After the patient has been sedated and propped in a can be fixed. From this leads an insulated flexible copper ~. sitting position, the skin is cleaned, draped and infiltrated wire (B), which is soldered to a brass collar with a screw , with a local anaesthetic solution. The pericardiocentesis (C). This serves as an electrical contact with a needle electrode is attached to the chest lead of the ECG. The shaft (D), as well as an adjustable depth guard. A home­ limb-lead electrodes are best strapped, since the suction­ made electrode can be produced from two pins of a cup electrodes become loose too easily. An assistant oper­ standard 5-amp. plug (Fig. 2). The electrode is sterilized in ates the direct-writing ECG, which is properly earthed, a solution of 'zephiran'. and has a full roll of recording paper. Earthing is essen­ tial because ventricular fibrillation may be induced by the ECG if insulation is imperfect. The aspirating needle is passed through the collar, which is firmly screwed to the shaft. Long needles and large syringes make close control difficult and should not be used. A two-way tap (Fig. 1 E) speeds up and facili­ tates aspiration. It helps to eliminate electrical interference to wear rubber gloves and handle the all-glass syringe only. With the needle under the skin and the lead selec­ tor left on the V position, ECG recording is begun. Base­ line drift must be controlled. While suction is applied the needle is slowly advanced under continuous ECG control. As soon as the needle comes into contact with the myocardium, an acute current of injury is recorded, viz. elevation of the S-T segment (Figs. 3 and 4). The needle need not actually penetrate the myocardium to produce changes, since it has been shown experimentally" that S-T segment elevation can occur when the pericardium is firmly indented against the epicardium. Ifaxiphoid approach is used the ECG may show elevated P-R seg­ Fig. 2. Home-made electrode from a standard 5-amp. plug. ments when the atrium is contacted."

Fig. 3. (A) Base-line drift can be seen while the needle is being advanced into the pericardium. As soon as the point comes into contact with the epicardium S-T segment elevation appears, and becomes extreme when the needle is inserted a few mm. deeper. (B) The difference between the ECG tracing with the needle in the pericardial sac and in contact with the myo­ cardium is well shown. -

15 Junie 1963 S.A. TYDSKRIF VIR GENEESKUNDE 639

Fig. 4. AI=entry; AII=exit; BI=needle in pericardium; BIl=needle in myocardium. (A) A continuous tracing taken during insertion and withdrawal of the exploring needle from the pericardial cavity. S-T segment elevation immediately alerts the operator to the proximity of the needle to the myocar­ dium. (B) The acute S-T segment elevation due to needling of the myocardium is clearly seen.

red in all these patients. Such accidents are ascribed to lack of alertness and delayed observer response. As soon as any ECG changes are observed the needle should be slightly withdrawn. If fluid is encountered, the collar is quickly loosened, slid down to the skin, and screwed fast. The ECG moni­ toring continues during aspiration and, should changes develop as the myocardium touches the needle tip, the needle should be withdrawn slightly until the ECG is once more normal. If the fluid is bloody and the ECG pattern remains unchanged a haemorrhagic effusion is pre­ sent. SUMMARY Continuous electrocardiographic monitoring during the performance of pericardial aspiration should become a routine procedure." The technique is described. I wish to thank Dr. V. Schrire, Director of the Cardiac Clinic, for his encouragement and criticism, as well as Mr. L. W. Piller, chief technician of the Cardiac Clinic, for con­ structing the electrode; also Dr. C. Rainier-Pope for his assist­ ance, the members of the staff of the Groote Schuur Hospital for referring cases, and the Superintendent, Dr. J. G. Burger, for permission to publish. This work was supported by the Council for Scientific and Industrial Research and the City Council of Cape Town. REFERE CES I. Bishop, L. H. jnr., Estes. E. H. jnr. and Mclntosh, H. D. (1956): J. Amer. Med. Assoc., 162, 264. The assistant must watch carefully for S-T segment 2. Schrire, V. (1959): S. Afr. Med. J .• 33, 810. elevation, since this may be slight and comes on suddenly.' 3. Neill, J. R., Hurst, J. W. and Renfold, E. L. J. (l96J): New Eng!. J. Med., 264, 711. Perforation of the myocardium in spite of ECG monitor­ 4. Lubell, D. L. and Glass, P. (1962): Dis. Chest, 41, 657. 5. Burch, G. E. and Phillips, J. H. (1962): Amer. Heart J., 64, 267. ing has been documented,' but significant changes occur- 6. Schrire, V. (1963): Clinical Cardiology, p. 252 .. London: Staples Press.

ANTIFIBROSIS THERAPY IN THE MANAGEMENT OF PULMONARY TUBERCULOSIS L. W. OSBURN, M.R, RCa. (RAND); T, C. M. HERCKENRATH, MED. DRs. ARTS. (UTRECHT); and G. SPE CE-SMYTH, M.D., ER.C.P. (IREL.), F.R.C.O.G., F.C.P.S. & G. (SA) Montebello Mission Hospital, Natal

A not uncommon occurrence during the treatment of and streptomycin, rarely show permanent dramatic pulmonary tuberculosis is the onset of pulmonary fibrosis response to other drugs. with a residual cavity showing no evidence of closure. In our opinion a greater certainty regarding the manage­ Rather, the cavity wall becomes denser as the surrounding ment and prognosis of pulmonary tuberculosis would be fibrosing process continues. The end result of treatment possible if fibrosis could be controlled, and the vascularity in such a case is often a patient who, despite being reason­ of the area of the lesion improved. This implies controlling ably well, is chronically sputum-positive. For a variety of fibrosis by means of systemic antifibrosis therapy. reasons resection of the cavity may be contraindicated. Although the range of anti-tuberculosis drugs appears Material and Method formidable in theory, 'the fact of the matter is that patients One of us had initiated trials of such a nature a year who do not respond satisfactorily to the basic INH, PAS ago using a certain drug, but the response obtained was