I wish to call attention to a fact which Flint has not mentioned, namely, the disordered action of the heart in idiopathic brain affections. In some cases of meningitis, and nearly all cases of tubercular meningitis, the pulse is at first full and irregular, afterwards soft and fluttering, then intermitting, irregular, full, slow and labored, easily quickened by motion or mental disturbance to double its previous amount of pulsations.
When we reflect that these symptoms also occur in pericarditis, we shall admit that it may be possible for the physician who neglects physical examinations to make a wrong diagnosis. I have seen cases of tubercular meningitis in which the beating of the heart and the character of the pulse simulated pericarditis. The physical signs on percussion were, however, wanting. In such cases the disorder of the heart was functional, or reflex, the nervous irritation being transmitted through the phrenic and pneumogastric nerves, just as in reflex disorder of the brain from pericarditis, but in a contrary direction. I will here remark, that for brain symptoms arising from diseases of the heart, digitalis is generally specific; but if the contrary obtains, it is not indicated.
PHYSICAL SIGNS OF PERICARDITIS.
The symptoms of acute pericarditis above enumerated are not alone sufficient to enable us to diagnose with certainty the presence of that disease. But by means of the physical signs obtained by percussion, auscultation, palpation, inspection, and mensuration, the disease may now be generally recognized with a degree of positiveness which clinical observers, not many years ago, regarded as unattainable.
Instead of entering into a profuse description of these signs occurring in pericarditis, I shall take the liberty to present the admirable summary given by Dr. Flint, in this work on Diseases of the Heart:
PERCUSSION.
“Enlarged area of praecordial dullness; the extent of this area greater in a vertical than in a transverse direction; its shape corresponding to the pyramidal form of the pericardial sac when distended; the dullness within this area, and the sense of resistance on percussion greater than over the praecordial region in health, or in cases of enlargement of the heart. These signs denote an abundant effusion within the pericardial sac.
“Moderate or small effusion denoted by increased width of the area of dullness at the lower and middle portions of the praecordial region. The increase of the area of dullness taking place within a few days or hours, and progressing rapidly; its extent varying on different days during the course of the disease. Dullness from the presence of liquid below the point of the apex-beat of the heart. Diminution of the area of dullness, with more or less rapidity in the progress of the disease toward convalescence, and its final reduction to its normal limits; when convalescence is established.”
AUSCULTATION.
“A friction sound developed, usually, soon after the commencement of the inflammation, depending on the exudation of lymph; rarely wanting during the period of the disease which precedes that of liquid effusion; frequently, not invariably, disappearing during the period of effusion; often returning after the absorption of liquid, and sometimes persisting after adhesion of the pericardial surfaces has taken place. Intensification of the heart sounds at the commencement of the disease, or prior to liquid effusion; during the period of effusion, both sounds weakened, but especially the first sound; the element of impulsion in the first sound notably impaired or lost, and this sound, therefore, consisting of the valvular element alone, resembling the second sound as regards quality and duration; the sounds apparently distant, and the apparent distance greater when the patient is recumbent on the back.
“Cessation of respiratory murmur and vocal resonance, concurring with the results of percussion, in determining the enlarged area of praecordial dullness dependent on distension of the pericardial sac.”
PALPATION.
“Prior to the period of effusion, the cardiac impulse abnormally forcible, violent, extending over a larger space than in health, and sometimes tumultuous beating of the heart. After effusion, the point of apex-beat raised, and carried to the left of its normal position. Suppression of the apex-beat, if the quantity of liquid be large. Return of the beat when the liquid diminishes. Vibration of the thoracic walls in the praecordia before, and sometimes after the period of effusion, constituting tactile friction – fremitus. Retardation of the apex-beat in some cases, after a certain amount of effusion, so that the first sound precedes it by a distinct interval.”
INSPECTION.
“Prominence or arching of the praecordial region in some cases during the period of effusion, if the pericardial sac be distended, observed chiefly in young subjects; the prominence presenting an indistinct outline of the pyriform shape of the pericardial sac. Restraint of the respiratory movements of the left side, if the quantity of liquid be large, and also, prior to effusion, in some cases, from pain felt in the act of inspiration. Undulatory movements in the intercostal spaces over the pericardium distended with liquid, in a very small proportion of cases. Depression of the praecordial region in some cases, after the absorption of liquid.”
MENSURATION.
“Prominence of the praecordia in some cases, produced by liquid accumulation in the pericardial sac, determined by callipers. Sudden development, or increase of prominence, and its sudden or rapid disappearance.”
DIAGNOSIS.
If the physician depends altogether upon the symptoms supposed to indicate pericarditis, he will find the diagnosis of the disease to be difficult, and often impossible. It has been shown that cases may occur which do not show symptoms of a positive character. It is only since the discovery of physical exploration, that the diagnosis is made comparatively easy. But since this method is still neglected to much extent, pericarditis is habitually overlooked by many medical practitioners.
There are many diseases having pathological relations to pericarditis, and during the progress of those diseases we should be on the watch for the earliest evidence of its development. During the progress of acute rheumatism the praecordial region should be daily explored with reference to the signs of pericarditis, as well as endocarditis. We may, in such cases, discover the friction-murmur before the patient makes any complaint of pain or other symptoms denoting that the pericardium has become involved.
In view of the fact that inflammation of the pericardium as well as other serous structures, is liable to be developed in patients affected with disease of the kidneys, we should not neglect to examine the chest from time to time.
The diagnosis of pericarditis from pleuritis or pneumonia is sometimes difficult. In such instances the heart should be closely interrogated.
We may hear a friction-murmur in pleuritis, produced outside the pericardial sac. It will be found difficult to discover the presence of liquid effusion in the pericardium when, at the same time, it exists in the left pleural sac; while, if the effusion is in the right pleural cavity, we can readily distinguish it from pericardial effusion.
Flint says that he has known acute uncomplicated pericarditis to be considered and treated, throughout the disease, as pleurisy, when the diagnosis was based on symptoms alone, and I have no doubt but such instances are very numerous, too numerous in fact for the dignity and honor of medical science.
Dropsy of the pericardium may be mistaken for the stage of pericarditis with effusion. But the former rarely occurs except in connection with general dropsy, and then not to the same extent as in pericarditis. Moreover, hydro-pericardium is not preceded by pain, tenderness, fever, etc., nor is it attended by the friction-murmur.
PROGNOSIS.
Pericarditis is always a serious affection, and its progress should be watched with great solicitude. In no disease must we attend so closely to the development of the various stages.
Different observers vary in their testimony as to the fatality of the disease. Dr. Hope declared that in ten years he did not lose a case. Of 106 cases analyzed by Louis, 36 died. In 84 cases reported by Latham, only 8 died. Of Dr. Flint’s 50 cases, 27 died; but these were unusually bad cases variously complicated.
According to Flint, pericarditis is least fatal when rheumatic; more dangerous when occurring during renal affections, eruptive and continued fevers, pyaemia; and generally fatal when associated with marked disorder of the nervous system, giving rise to mania, tetanus, chorea, etc. Under judicious homoeopathic treatment this rate of mortality would probably have been less. Dr. Russell’s success in the London Hospital was certainly very satisfactory.
The duration of the disease is variable. It may prove so rapidly fatal as to kill in 24 hours. It lasts usually from one to two weeks, and, if not ending fatally in this time, ends in recovery, or the chronic form.
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.