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CHAPTER XIV.

OF THE PHLEGMASIE OF THE SANGUIFEROUS SYSTEM.

Pericarditis.

INFLAMMATION of the pericardium is no very uncommon affection, and from the very important functions assigned to the parts immediately implicated, must be regarded as one of the most alarming and dangerous of phlegmasial diseases.

The symptoms which usually attend the acute form of the disease, are-sudden severe lancinating pains in the centre or cardiac region of the chest, extending occasionally to the epigastrium, or to the back between the shoulders, attended with more or less oppressive dyspnoea, palpitation of the heart, and a sense of weight and constriction under the sternum and left side of the thorax. In most instances the patient is entirely incapable of lying down, more especially on the left side. He is constrained to remain, almost immoveably, in the sitting posture, leaning the body slightly forwards, and resting his head on the back of a chair or some other sufficiently elevated support. The slightest variation from this posture, unless very cautiously effected, is apt, in some cases of this kind, to give rise to sudden and most poignant pains in the region of the heart. Extreme præcordial anxiety, with a dry and short cough, usually attend; and in many instances, partial syncope or sudden feelings of great faintness occur, at intervals, during the progress of the disease. Along with these symptoms we have also strong evidence of cardial disturbance in the state of the pulse. In most instances, the pulse is remarkably irregular, intermitting, frequently feeble, and sometimes so small as to be almost imperceptible. A few cases, indeed, have been recorded, in which the pulse remained in nearly a natural state. Tacheron relates an instance of this kind.* The face is generally pale, with an occasional cireumscribed flush on one cheek; the prolabia become more or less livid as the disease advances, and a slight puffy swelling is apt to occur about the eyes and temples. The hands and feet usually become slightly edematous in the latter stage of the disease; and great general weakness almost always ensues soon after the full development of the inflammation. The speech is commonly faltering, and in some cases the patient is unable to spit out, without giving rise to sudden and extremely severe darting pains in the region of the inflamed organ. Sometimes considerable headach attends, and occasionally much uneasiness and pain is expe

* Recherches Anatomico-pathologiques, &c. &c.

rienced in the stomach, accompanied with tenderness to pressure in the epigastrium.

It must not be supposed, however, that pericardial inflammation is invariably attended with the train of symptoms just described. There are few phlegmasial affections so liable to such remarkable variations in the attending symptoms, as the disease under consideration. In some cases very little or no pain is experienced in the region of the heart; and the disturbance of the heart's action varies greatly in different cases, or at different stages of the same case. Most commonly the heart palpitates tumultuously, and knocks violently against the ribs; but in some cases, its action is so feeble that its pulsations are scarcely to be felt or heard. Although the majority of patients are obliged to remain in a sitting or semi-recumbent posture, yet some are forced to lie immoveably on their backs, or on the right or left side. "But the strangest anomaly is, that the same patient, who at one period of his disease has fixed himself immoveably on the left side, will, at another, be forced to turn over and fix himself as immoveably on the right side." (Latham.)

Pericarditis is not unfrequently complicated with inflammation of the neighbouring structures, as the pleura, lungs, mediastinum, diaphragm, or stomach; and in some cases the substance of the heart itself participates in the pericardial inflammation. In instances of this kind, the symptoms are, of course, correspondingly complex.

Diagnosis. From the complications just mentioned, the diagnosis of pericarditis is often attended with much difficulty; and Laennec cautions, in all instances, against "too implicit a confidence" in the symptoms mentioned above as manifestations of pericardial inflammation. Pericarditis, he says, may exist without any of these signs; and on the other hand, all of them may be present, without the slightest inflammation of the pericardium. M. Louis, however, asserts, that from a careful observation of thirty-two cases of this affection, he has been led to believe that the diagnosis is by no means so difficult and uncertain as is supposed by Laennec and others. This, he says, may be asserted, at least, of those cases that are free from complications. Where we find severe lancinating pains in the region of the heart, extending at intervals to the back and epigastrium, attended with palpitation of the heart; great irregularity, intermission, and smallness of the pulse; difficult respiration; occasional syncope or great faintness; inability to rest in the recumbent position, with more or less oedema of the extremities, we may infer, without much risk of erring, the existence of pericardial inflammation. If with these symptoms we find the cardiac region yielding an obscure or dull sound on percussion, while the other parts of the chest are resonant, the correctness of the diagnosis will hardly admit of a justifiable doubt. But, although we may, with but little risk of mistake, infer the existence of pericarditis when the foregoing symptoms are present, it is well ascertained that rapid and violent pericardial inflammation sometimes occurs, and

proceeds to a fatal termination, without at any period of its course manifesting a single symptom indicative of cardial disease. It is a very remarkable fact also, that cases of this kind occasionally simulate inflammation of the brain so closely, that no one could for a moment hesitate to regard the disease as an instance of strongly marked encephalic inflammation. Dr. Latham has recorded several highly interesting cases of this kind. "One of the children at Christ's Hospital, had in the opinion of all who saw him the severest inflammation of the brain. The attack was sudden, with great heat of the skin and frequency of the pulse. He had delirium and convulsions, and pointed to the head as the seat of his pain." On dissection, not the slightest trace of inflammation within the head was discovered, but the heart and pericardium were intensely inflamed. M. Andral also relates a case where delirium, general convulsions, twitching of the tendons, and finally tetanic spasms, followed by paralysis of the upper extremities and fatal coma, occurred without the least sign of any particular affection of the head. On dissection, the brain, spinal marrow, and their membranes, did not present the slightest traces of disease. But the pericardium exhibited strong marks of inflammation; its surface was covered with a layer of concreted lymph, and several ounces of a green and flaky serum was effused into its cavity.*

Causes. In general, whatever is capable of causing inflammation of any of the thoracic organs or structures, may give rise to pericarditis. Cold; mechanical injuries; the sudden healing up of old ulcers; the suppression of habitual evacuations; repelled cutaneous affections; the influence of the depressing mental emotions; and over exertion of the mind; may produce the disease. Metastasis of rheumatism and gout, is, however, by far the most common cause of this affection. Rheumatic irritation especially, is frequently concerned in the production of cardiac affections. Under the head of hypertrophy, its tendency in this way will be particularly noticed. Pleuritis and pneumonia sometimes involve the pericardium.

Autopsic phenomena.—In most instances a considerable quantity of serum is found in the pericardium. Louis mentions cases in which more than a pint and a half of reddish or yellowish serum was collected; and Corvisart saw an instance where it amounted to four pounds. The internal surface of the pericardium is generally much injected, and often rough and uneven, or covered with more or less extensive patches of false membrane. In some cases a similar pseudo-membranous formation covers the surface of the heart. M. Louis mentions one where false membrane, nearly half an inch thick in some places, covered the heart, so as to give it the appearance of the rind of a pine apple. Laennec asserts that the quantity

Pathological Essays on some of the Diseases of the Heart. By P. M. Latham, M. D. Physician to St. Bartholomew's Hospital. Lond. Med. Gazette,

of serum effused into the pericardium, though considerable in the early stage of the disease, always decreases progressively, by absorption, as the violence of the inflammation declines. In cases of great violence, there is generally very little or no serum effused; but instead of this, a large portion of firmly concreted albumen usually covers the heart and internal surface of the pericardium, and in some instances, fills the whole cavity of this membrane, uniting it more or less firmly with the surface of the heart.* In cases that terminate favourably, this albumenoid concrete matter gradually becomes converted into cellular substance, "or rather into lamine of the same nature as the serous membranes." In some cases the pericardium is found very firmly adherent to the heart throughout its whole extent, by means of laminæ of cellular structure thus formed. Cases are mentioned by some of the older writers, where the pericardium was supposed to be altogether wanting; but these were no doubt instances of firm adhesion of this membrane to the heart. Columbus relates the case of a student at Rome, who after having for a long time suffered frequent attacks of syncope, died suddenly. On dissection, the heart, he says, was found unprotected with a pericardium.† The pericardium has also been found affected with true scirrhous induration; and Dr. Friend asserts that he has found it above half an inch in thickness throughout its whole extent.‡

Chronic Pericarditis.—The chronic form of pericardial inflammation appears to be much more frequent than the acute, It is attended, in most instances, with more or less fixed pain in the region of the heart, subject to occasional exacerbations, particularly from even slight perturbating causes. Some degree of dyspnoea and pectoral oppression is seldom wholly absent; and a short dry cough is apt to occur. The pulse, as in the acute form of the complaint, is small, and at times irregular and intermitting; and the heart is apt to be thrown into violent paroxysms of palpitation by slight corporeal exertions and mental excitement. Patients labouring under this affection, are generally timid, pusillanimous, and disturbed by apprehensions of evil, or of death. On percussion, the sound elicited over the region of the heart, is peculiarly dull; and when effusion. has taken place, some degree of fluctuation may be felt by the patient. In most instances, oedema of the lower extremities occurs, and occasionally a puffy swelling appears suddenly in the face, particularly under the eyes, and after a day or two disappears again.

When the sound on percussion over the cardial region is dull, and the extremities and face become puffy, we may conclude that considerable effusion of serum has taken place in the pericardium; and in this case the danger is always very great. Death from this affection often occurs very suddenly and unexpectedly; but in some

* Laennec.

+ De Re Anatomica, lib. xv. p. 267-as quoted by Van Swieten.

History of Physick, p. 2.

VOL. I.-49

instances a slow wasting of the body, and declension of the vital powers, under symptoms of general febrile irritation, gradually lead to a fatal termination.

On dissection, the whole internal surface is, usually, found florid; but the pseudo-membranous exudation, so common and conspicuous in acute pericarditis, is but rarely met with in this form of the disease. When albumenoid concretions of this kind do occur in chronic pericarditis, they are always "thin, soft, friable, and entirely resembling a layer of very thick pus." (Laennec.) The substance of the heart presents a whitish colour, "as if it had been macerated, several days, in water;" and it is sometimes of a much softer consistence than natural, whilst in other instances it possesses its normal degree of firmness. Laennec does not agree with those who suppose that the loss of colour in the muscular substance of the heart, is the consequence of inflammation; but he does not advance any facts which can be deemed sufficient to repudiate this opinion.

Treatment. A direct and active antiphlogistic treatment, is of course the only mode of management upon which any reasonable hopes of success can be placed. In cases attended with symptoms of pulmonic inflammation, the treatment should, in every respect, coincide with that which would be adopted in either pneumonia or pleuritis. Where the pericardial inflammation has supervened suddenly, soon after the disappearance of external rheumatic inflammation, blood-letting cannot, in general, be carried to the extent which is proper in cases arising from other causes. Indeed, the ordinary antiphlogistic means usually employed in phlegmasial affections, will rarely subdue rheumatic pericarditis; and copious abstractions of blood, are not unfrequently productive of serious mischief. In cases of this kind, calomel and opium, given in full and frequent doses, in conjunction with moderate general and local depletion and proper revulsive applications, constitute the most valuable curative means we possess. Dr. Latham speaks in the most favourable terms of the employment of mercury in pericarditis. It is particularly valuable in rheumatic pericarditis, although much advantage may often be obtained from its use in every variety of the disease. "From acute pericarditis," says Dr. Latham, "which has proceeded to the deposition of lymph, nothing, I believe, can effect a perfect recovery, except mercury, given so as to excite moderate salivation." From my own observations, I am entirely convinced that calomel given to the extent of producing a general mercurial impression, is a valuable remedy in this affection. Where the disease is dependent on rheumatism, it will, I think, always be best to give the calomel in union with opium. In a case of rheumatic pericarditis, which came under my care about six months ago, I prescribed one grain of opium with three grains of calomel, every four hours, with unequivocal benefit. About sixteen ounces of blood were abstracted with the lancet, and thirty leeches applied to the region of the heart, before the calomel and opium were resorted to.

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