Pericarditis

“ TREATMENT OF ACUTE PERICARDITIS In acute pericarditis, absolute mental as well as physical rest is essential. Even if the patient does not appear to be seriously ill and has not much fever, he should not be allowed to have visitors, to discuss business matters, or to carry on any conversation, however little exciting. Anything which increases the heart beat increases the irritation of the inflamed surfaces of the pericardium. He should not be allowed to sit up, either to eat or to attend to the calls of Nature. ”

“ In pericarditis it is perhaps well always to administer an alkali in some form unless otherwise contraindicated, whether or not the cause is rheumatism. A diminished alkalinity of the blood would always increase the likelihood of an augmented amount of pericardial or endocardial inflammation. The blood must be kept strongly alkaline. It is possible that one of the reasons why pericarditis or endocarditis occurs so frequently in serious prolonged fevers is that the patient has not eaten enough cereals or other carbohydrates, and the system has become more or less endangered by acidosis. ”

“ When the diagnosis of pericarditis has been arrived at it is desirable to determine the exact nature of the disease, for whilst cases of pericarditis due to foreign bodies are incurable and in the interest of the owner the animals should be slaughtered, pericarditis due to cold or rheumatism may be successfully treated. Rheumatism generally affects the synovial membranes even before it produces pericarditis, and this indication, supplemented by the history of the case usually ensures one against mistakes regarding the initial cause. ”

“ Pericarditis often proves fatal but it is by no means invariably so in uncomplicated cases. There is especial danger when serous effusion is excessive, when it occurs in a weak and debilitated subject, or when it is complicated by pleurisy, influenza or rheumatism. The preliminary chill may be met by the measures advised for the rigor of pleurisy, but if the malady is developed other treatment is required. ”

“ During the development of pericarditis the foreign body perforates the reticulum and diaphragm, passing along the middle line of the body, without which it would not come in contact with the pericardium. If the perforation, however, occurs to the right or left of the median plane, the foreign body moves forward just as easily, but it misses the pericardium and passes either into the lung, where it causes fatal pneumonia; or the pleura, where either it sets up septic pleurisy in the subpleural connective tissue or produces an abscess. ”

“ Pressure is rather exercised upon the parts in the mesial line. They reach a large size and grow with great rapidity, producing symptoms rather as a consequence of their size than by virtue of contractile properties.
From Pericarditis.—A possible pericarditis may be mistaken for a tumor of the anterior mediastinum. The diagnosis of pericarditis must be sustained by evidence showing the dependence of this process upon rheumatism, syphilis, nephritis, or propagated inflammation. The distension of the pericardial sac due to pericarditis exhibits a definite outline. ”

“ A temperature of 105° is always grave. The prognosis of pericarditis in Bright's disease is, speaking in general terms, as unfavorable as that of the pericarditis of acute rheumatism is favorable. The pericarditis of poisons, of pyæmia, or of scurvy is, as a rule, a very serious malady. In the exanthemata recovery is the rule, unless there be extensive pleurisy or pneumonia as a complication. ”

“ There is apt to be hectic, with headache, delirium, and syncope. In fact, there is no symptom of pericarditis or of hydropericardium which may not also be found in acute mediastinitis or in the accumulation of pus in the mediastinum. Where the inflammation can be traced to an injury, as a blow upon the sternum, or where there exists caries or necrosis of the sternum, the diagnosis is greatly facilitated. The inflammatory symptoms, while of all grades of intensity, are, as a rule, more intense in the forms of mediastinitis than in any of the acute stages of pericarditis. ”

“ All these symptoms are due to the existence of adhesions between the heart and pericardium, which, by destroying the interpericardial space, interfere with diastole while preventing regular systole.
Sudden death is a frequent consequence.
The diagnosis of chronic pericarditis is very difficult. The prognosis is extremely grave, and we do not possess any means of dealing with the condition. ”

“ When this disease is developed in the course of rheumatism, it is known as rheumatic pericarditis, and is almost always associated with endocarditis. In some cases acute pericarditis is very distressing, in others it is mild. The fatality is not due so much to the disease itself, as to co-existing affections. ”

“ In pericarditis the result of the exanthemata, of Bright's disease, of scurvy, of tuberculosis of the lungs or elsewhere, of profuse drainage from abscesses or injuries—of, in fact, any wasting disease or fault in the economy associated with malnutrition—the pericarditis may be subacute at first, and is then apt to become chronic. ”

“ When the disease is associated with influenza or rheumatism, some of the symptoms may be obscure, but a careful examination will reveal sufficient evidence upon which to base a diagnosis. When pericarditis develops as a result of or in connection with pleuritis, the distinction may not be very clearly definable, neither will many recover. When it results from a wound or broken rib, it almost invariably proves fatal. ”

“ Acute interstitial myocarditis occurs in connection with the infectious fevers, and also with pericarditis, more rarely endocarditis. It is characterized by the presence of numerous round cells in the interfibrillar tissue, multiplication of the corpuscles, and degeneration, granular or fatty, of the muscle-fibres. The coarse appearances are—a relaxed state of the cardiac walls, pale or turbid condition of substance, in extreme instances a sodden, soft friable state, so that the muscle readily tears on pressure. ”

“ Other causes of simple pericarditis may be blows upon the breast, as with the fist; crushing or compression, as in railway accidents; penetrating wounds, as from gunshot or knife; and injury from foreign bodies in the oesophagus, such as pins, false teeth, etc. Buist1 records a case of a man who swallowed a plate with artificial teeth attached. The plate, becoming lodged in the oesophagus, finally penetrated the pericardium posteriorly and produced fatal pericarditis. A similar case is recorded by Flint.2 ”

“ Mistakes are not very likely. Only in some cases are they liable to occur, as in acute peripneumonia of the anterior pulmonary lobes, causing compression of the pericardium of the anterior vena cava and producing secondarily venous stasis and œdema of the dewlap. Cases of specific pericarditis due to peripneumonia also occur, and under such circumstances a mistake would be even more excusable. Nevertheless, the temperature curve in itself is a sure indication, for whilst in peripneumonia the fever is always very marked, it is scarcely noticeable in pericarditis due to a foreign body. ”

“ It is much more difficult to distinguish pericarditis due to a foreign body from pericarditis due to carcinoma and from the forms of pseudo-pericarditis produced by lesions in the neighbourhood of the heart. ”

“ The causes of death in pericarditis are various. Death may occur in a few hours after the attack by the rapid effusion of a large quantity of fluid, compressing and causing mechanical paralysis of the heart; or it may happen from syncope due to the patient making sudden exertion, as in getting out of bed, more especially if there be a large amount of fluid in the pericardium; or, again, it may be owing to paralysis of the heart from disturbance of the cardiac centres, or to fatty degeneration of the cardiac walls largely induced by the inflammatory condition. ”

“ The change from the acute to the chronic form may occur in a very few days, or even in less time, and an autopsy would not reveal anything to determine the fact. Pericarditis in any form is apt to be associated with pleurisy, and adhesions between the pericardium and adjacent pleura are common. In some instances the distended sac is adherent to the back of the chest. By its pressure on the lung and the oesophagus it may produce secondary lesions in them as well as in the phrenic nerves. ”

“ Acute endocarditis can probably not occur without some inyocarditis, and myocarditis probably does not occur without some endocardial disturbance and perhaps some pericardial irritation. This is especially true in endocarditis which occurs during any acute infection, even in rheumatism. The greater the amount of pericarditis, the more serious is the acute condition. The greater the amount of myocarditis, the more doubtful is the heart strength in the near future. The greater the amount of endocarditis, the greater the doubt of freedom from future permanent valvular lesions. ”

“ In acute pericarditis grave implication of the myocardium may be suspected when the pulse gets small and rapid, dyspnoea urgent, and the cardiac pain is increased. Such symptoms, in the absence of copious effusion, would appear to indicate extension of the inflammation to the heart-muscle. Even the occurrence of suppuration has no distinctive symptoms, as it almost invariably occurs as part of a pyæmic process, and the cardiac weakness which supervenes may be regarded as an outcome of the septic or febrile condition. ”

“ On percussion the thorax may appear of normal resonance throughout; but when pleural lesions and exudates exist, resonance gives place to partial or complete dulness. Should pericarditis or small cardio-pericardial adhesions exist, they may escape observation, but if the exudate is abundant or the adhesions multiple or of large size the usual symptoms of pericarditis develop progressively.
On auscultation the respiratory murmur is always found to be greatly exaggerated in the healthy parts, usually the upper portions of the lung. ”

“ If the pericarditis has been the result of sharp pointed metallic bodies swallowed and afterwards making their way to the heart, it is sometimes preceded by eructations, tympany, difficulty in swallowing or in rumination, and by dropsy under the sternum, but more frequently the heart symptoms are the first to be noticed. ”

“ It may not be easy in many cases to determine the traumatic or other condition in which the apparent simple acute pericarditis originated. The weight of evidence is so much in favor of traumatism as a preceding and efficient cause of simple acute pericarditis that a diligent search should always be made for the same. ”

“ He also shows that while pericarditis affects the two sexes below the age of twenty-one in nearly equal proportions, after the twenty-fifth year males are three times oftener subject to it than females. The disease is greatly modified by occupation as well as by age. Thus, Sibson has pointed out that female domestic servants under twenty-one years of age are extremely prone to acute rheumatic pericarditis, endocarditis, and carditis, as they are often unequal to labor and fatigue, and are easily affected by draughts and by exposure to wet and cold. ”

“ Chronic Pericarditis is sometimes seen in the ox without any preceding acute attack. This is manifested by the local symptoms without the accompanying acute fever. Along with a slight fever, there is the oppressed breathing aggravated by exertion, the weak irregular or intermittent pulse, the weak or distant heart sounds, the absence of respiratory sounds and the dullness on percussion over a space represented by an inverted cone at the anterior part of the chest on each side, the venous pulse in the neck and the general tendency to dropsy. ”

“ In cases of fibrinous mediastinitis associated with fibrinous or fibro-purulent pericarditis, Kussmaul has called attention to the diagnostic value of a pulse intermitting at regular intervals simultaneously with inspiration, the pulsus paradoxicus.
PROGNOSIS.—The prognosis of pericarditis is exceedingly variable, depending largely upon the primary cause, the intensity, the stage and duration of the attack, the prior condition of the individual, and his surroundings. ”

“ Real pain is seldom present unless the pericardium is affected. If the myocardium is much inflamed at the same time, the heart becomes more rapid and the blood tension lowered, and the apex beat diminished in intensity and perhaps not palpable. If there is pain, with or without pericarditis, it is often referred to the epigastrium, especially in children. The patient is often nervous, restless and sleepless. In simple endocarditis emboli rarely occur. ”

“ Of the several forms of rheumatic cardiac inflammation, endocarditis is the most frequent, and in a large proportion of cases it may exist alone; pericarditis is also very often observed, but it seldom is found per se, being in the vast majority of cases combined with endo- and occasionally with myocarditis. It is generally the ordinary verrucose endocarditis that obtains. ”

“ Between these adhesions, which form partitions, are found little cavities filled with sero-sanguinolent, grumous, or caseous liquid. In time the adhesions increase in number, pericarditis obliterates the free space, and the heart becomes wholly adherent to the pericardium.
As in acute pericarditis, the fibrous layer undergoes thickening and hardening processes. The superficial layers of the myocardium undergo sclerous transformation, and the tissues forming the adhesions themselves may assume the characters of fibrous tissue. ”