Symptoms referable to the heart, (1) pain, (2) tenderness, (3) palpitation.
Pain referred to the praecordia is a prominent symptom in some cases. It is generally burning, lancinating, and often accompanied by a sense of constriction. It is aggravated by inspiration and the movements of the body. The pain is sometimes felt in the epigastrium, or to the right side, or the centre of the sternum. It may extend to the back, to the left shoulder, and down the left arm, as in angina pectoris. The pain much resembles the pain of pleurisy, with which pericarditis may be confounded. The two diseases may, however, exist at the same time; so also may pleurodynia and intercostal neuralgia. But pain in pericarditis may be very slight, or altogether wanting. Dr. Flint says, in the larger number of cases observed by him, the pain was very slight.
It is a disputed question on what the pain depends. Bouilland attributes it to co-existing pleuritis. Flint refers it to the nerves of the heart. Inman says it is a myalgia of the thoracic muscles.
Tenderness on pressure is generally present, but, like pain, varies in degree, and is rarely very marked. Hope says it may be discovered by pressing on the epigastrium beneath the cartilages of the ribs, in a direction toward the heart, when it is not apparent directly over the heart. Flint asserts that in order to constitute a symptom of pericarditis it must be limited to the region of the heart. If tenderness is diffused, it indicates the presence of pleurisy, or pleurodynia. It is only when taken in connection with other symptoms, that tenderness is of positive value. It is well known that in peritonitis tenderness is sometimes absent; so in pericarditis. Why this is so has not been explained.
Increased action of the heart occurs in pericarditis in the early part of the disease. The contractions are violent, and sometimes irregular, and the patient is conscious of an unnatural beating of the heart. This symptom, however, is by no means constant, and of itself is of little value, because it is found in functional disorder and organic disease.
If, during the occurrence of rheumatism, tumultuous action of the heart is noticed, it should lead to a careful examination.
In the stage of liquid effusion, palpitation cannot occur to any degree, and if the effusion is absent the heart is so weakened in the second stage as to make palpitation almost impossible.
SYMPTOMS OF THE CIRCULATION.
The pulse alone, in this disease, does not furnish positive diagnostic information, but when the diagnosis is made, it aids us in judging of the condition of the heart. At the outset of the disease it corresponds to the increased muscular action of the organ, and is strong, quick, and vibratory, more or less frequent, and sometimes irregular.
As the heart becomes weakened the pulse becomes enfeebled; and when, together with a certain amount of paralysis, there occurs liquid effusion, the pulse becomes weak and small, with greater disturbance of rhythm.
Walshe says that the frequency of the pulse “is subject to more sudden variations from the influence of emotional excitement and effort in this than in any other disease.” He adds, that he has known a gentle movement of the trunk to raise the pulse from 80 or 90 to 130 or 140.
But to the above statements there are many exceptions. Even in the first stage it may not be more frequent than in health. Graves says it is often “less frequent.” It may even continue regular, and in no way abnormal.
Lividity of the lips, face, etc., may be due to a weakness of the heart, and belongs to the second stage of the disease, when it denotes serious obstruction. It is attended with feeble and irregular pulse.
Lividity is caused by congestion of the venous radicles, but generally involves some affection of the pulmonary system co- existing with pericarditis. The efficient aeration of the blood by the lungs may in such cases cause lividity. This symptom is not therefore very important as a diagnostic sign of pericarditis.
RESPIRATORY SYMPTOMS.
Respiration is sometimes accelerated in pericarditis in consequence of the inspiratory acts being shortened by the praecordial pain, and, in such cases, dilatation of the alae nasi may be observed, the dyspnoea may be dependent on congestion of the lungs, incident to compression of the heart by liquid effusion, but it may be absent even when the pericardial sac is largely distended. But this symptom is not always present, for the respiration may be unaffected, or only accelerated by the febrile movement.
Cough, dry, hacking, or spasmodic, is common, and may exist independent of any pulmonary disease. It may, however, be absent in all stages. When a dry, short cough is associated with orthopnoea, a frequent and feeble pulse, and lividity of lips and face, it denotes imminent danger.
The voice may be very weak, the patient being unable to speak, except in feeble tones and with great effort. This symptom seems to be connected with copious effusion.
GASTRIC SYMPTOMS.
Vomiting is sometimes present and persistent, and may lead us to a faulty diagnosis in mistaking the attack for gastritis.
Dysphagia occasionally occurs, and was first noticed by Testa, an Italian author. It may be a spasmodic affection, or due to pressure of the distended pericardial sac upon the oesophagus.
SYMPTOMS OF THE COUNTENANCE, POSITION, ETC.
An expression of anxiety, or apprehension, is often a prominent symptom. The risus sardonicus has been observed in seven cases which terminated fatally. The position of the patient is generally on the back, or diagonally, between that on the back and on the side. It is rarely on the left side, the liver in this position pressing on the heart. In some cases the patient can lie comfortably on the right side. Generally, the patient desires to have the head and shoulders raised. But whatever position the patient selects he is very reluctant to change it, owing to the great increase of the pain or distress, and the excitement of the heart, which gives rise to a feeling of syncope, especially when the sac is filled with fluid. Fatal syncope has been induced by change of position. Flint refers to several cases, and I have observed it to occur in one case of rheumatic pericarditis, and in several cases where cardiac disease was complicated with diphtheria.
SYMPTOMS OF THE NERVOUS SYSTEM.
In addition to the mental anxiety, depression, and fear of death observed in cases of pericarditis, actual delirium may exist. It has not been considered an element of the disease.
There are, however, cases of pericarditis in which the cerebral symptoms are so marked that they mask the cardiac inflammation. These cerebral symptoms may simulate meningitis, mania, dementia, coma, epilepsy, tetanus, and chorea. In many cases of supposed cerebral disease terminating fatally, autopsy shows no appreciable lesion of the brain and spinal cord. But if the examination had included the heart, pericarditis would have been found to have existed.
Dr. Burrows* *”On Disorders of the Cerebral Circulation and on the Connection between Affections of the Brain and Diseases of the heart.” was the first to call special attention to this connection of cerebral symptoms with cardiac disease. Dr. Flint alludes to several interesting cases of a similar character which came under his observation. These two authors show conclusively that the physician may mistake an inflammation of the pericardium for an inflammation of the brain. In the 16 cases detailed by Burrows there occurred delirium, convulsions, agitation of the limbs resembling chorea, dementia, coma, and seizures resembling apoplexy and tetanic spasms. Flint’s cases had delirium, with wild, staring expression, inability to protrude the tongue, shouting as if from danger, coma, great agitation, blindness of one eye, etc. One patient “ejected saliva with great force, and in all directions.”
Several cases have come under my own observation. One very notably case, in a girl eight years of age. The symptoms all simulated meningitis, and it was only when my attention was called to the heart by the full and very irregular pulse, that physical examination disclosed the presence of pericarditis.
Flint says the delirium is peculiar, “the patient lying in a species of coma vigil, the eyes open and fixed in one direction, not replying to questions, and incapable of being roused; this state was followed by maniacal excitement, the patient shouting, and apparently laboring under fear of harm, with occasional ebullitions of hilarity. A fixed delusion of having committed some crime appears to be a distinguishing feature.”
From the above symptoms – and this peculiar delirium does not occur in meningitis – and also the absence of acute pain in the head, throbbing of the carotids, injection of the eyes and face, we may know that the disease is not cerebral. The delirium resembles somewhat delirium tremens, in which condition the heart is often much disordered. This fact may lead us to understand the curative action of digitalis in mania a potu.
Hale wrote Lectures On Diseases Of The Heart, Materia medica and special therapeutics of the new remedies Volume 1, Materia Medica And Special Therapeutics Of The New Remedies Volume 2, Saw Palmetto: (Sabal Serrulata. Serenoa Serrulata), The Medical, Surgical, and Hygienic Treatment of Diseases of Women, New Remedies: Their Pathogenetic Effects and Therapeutic Application, Ilex Cassine : the aboriginal North American tea, Repertory to the New Remedies with Charles Porter Hart, The Characteristics of the New Remedies, Materia Medica and Special Therapeutics of the New Remedies, The Practice of Medicine, Homoeopathic Materia Medica of the New Remedies: Their Botanical Description etc.