Acute Plastic Pericarditis.
Synonyms.—Fibrinous Pericarditis; Dry Pericarditis.
Etiology.—This form of pericarditis occurs more frequently in the young and middle-aged than at any other period of life, and occurs in males far more frequently than in females. It may be divided into primary and secondary forms.
The primary form occurs very rarely, though bruises or injuries of various kinds may result in so great an irritation and determination of blood as to give rise to inflammation. The old idea, once so prevalent, that cold was the exciting cause, is rapidly giving way before more careful observation and experimentation, and nearly all writers are now agreed that pericarditis is a secondary affection. Metchnikoff goes so far as to declare that there can be no such a condition as idiopathic pericarditis.
First in importance as a causal factor may be classed rheumatism; Bouillard declaring that in every case of rheumatism there will be some lesion of the heart; and while we regard this as a very extravagant statement, we may be quite conservative and yet place rheumatism as the cause in at least fifty per cent of all cases of pericarditis.
Chronic nephritis and tuberculosis may give rise to the acute form, but is more common in the subacute variety. Toxins from the infectious diseases seem to influence the pericardium quite early, resulting in inflammation. Scarlet fever, measles, diphtheria, influenza, and tvphoid fever in particular, give rise to it, though any infectious fever may have its influence in the same direction.
The extension of the inflammatory condition from neighboring organs, especially pleurisy and pneumonia, is a frequent cause, more of this form than of the other varieties. Carcinoma by poisoning the blood and encroaching upon neighboring tissues may give rise to this form.
Pathology.—The changes that occur may be general or local, usually the latter, and are similar to those which occur in pleurisy and peritonitis. At first the membrane is red, smooth, injected, and swollen, but soon becomes rough and thickened by the deposit of a fibrinous exudate. As a result of the friction of the surfaces, the membrane becomes roughened or wrinkled, resembling tripe in appearance, and when the exudate is thick, this friction results in giving the membrane a jagged-looking surface, giving rise to the shaggy or hairy heart of the older writers.
In this variety there is but little serous fluid, the natural secretion being arrested or greatly diminished. The myocardium may also be affected; in fact, there can scarcely ever be a severe pericarditis without involving more or less the heart itself. Where the disease has continued for some time, the heart is apt to be flabby and dilated, with more or less fatty degeneration.
If adhesions of the two surfaces have taken place, there is apt to be hypertrophy of the heart. At other times the nutrition of the heart is so impaired as to give rise to atrophy.
Symptoms.—Primary Form.—If the disease is primary, which is very rare, and if the patient be a young subject, there will be a chill, followed by a febrile reaction, a dry skin, scanty secretion of urine, constipation, and the general symptoms of an inflammation.
There is pain in the precordial region that varies from a dull, aching sensation to one of an intense, sharp, lancinating character, which extends from the nipple to the back and down the left arm. There is a sense of great anxiety, and though there may be but little pain. the patient has an anxious expression that can not be disguised. The pulse varies from one hundred to one hundred and thirty per minute, and in the early stage is full and strong.
If the pleura is involved, there will be embarrassed respiration.
Secondary Form.—Since the very large per cent of cases of pericarditis is preceded by some other disease, the symptoms relating to the heart are more or less obscured, and often the disease is entirely overlooked and the discovery made post-mortem. In confirmation of this is a statement made by an ex-intern of our city hospital, that of five post-mortems that came under his observation where pericarditis was found, not a single case had been diagnosed during life.
If the inflammation be very acute, pain of greater or less intensity will be felt in the precordial region, extending to the left arm, with more or less constriction in the precordial -region. Dyspnea is often present, but not a constant feature. The pulse is increased in frequency, and, though full and bounding in the early stage, becomes more feeble in long protracted cases. The fever that attends is rarely severe in character, the temperature not often exceeding 102°.
Physical Signs.—Inspection, if the patient be spare, may reveal increased force of the apex-beat. In severe cases the veins of the neck are swollen, and the pulsation of the jugulars are visible.
Palpation.—Palpation may reveal friction fremitus, which is due to the rubbing of the changed pericardial surfaces one upon the other, and is most intense to the left of the sternum. During the early and later stages it is more readily detected, there being but little effusion at these stages.
Percussion.—But little, if any, information is gained by percussion.
Auscultation.—The most positive information, and we might say pathognomonic signs, are obtained by auscultation. The pericardial friction rub is due partly to the exudate and partly to the dry condition of the membrane. This sound is usually double, and corresponds to both diastole and systole, though it may be triple and sometimes quadruple.
The sound is generally more pronounced than endocardial murmurs, and is harsh or creaking, resembling the sound of bending new leather, the sounds becoming more smooth and diffuse as the effusion increases.
The maximum sound is heard between the fourth and fifth interspace near the sternum. The sound is intensified bv changing the pressure of the stethoscope, moderately firm pressure giving the maximum sound, while very firm pressure causes it to entirely disappear.
The intensity of the sound is also influenced by the respiration, being usually louder on inspiration, though occasionally louder on expiration. Change of position will also influence and modify the sounds; thus the sitting position gives greater intensity to the sounds than when the patient is lying down.
Diagnosis.—In some cases the diagnosis is very readily made, while in others it is quite difficult, and in some cases impossible. The most positive sign is the characteristic friction rub, and to the skilled and practiced ear, the harsh rubbing or creaking sound near the ear is readily distinguished from the blowing and more distant sound of endocarditis.
We would recognize it from valvular lesions by the more constant and long-continued adventitious sounds of the latter, and also by the fact that change of position from the sitting position to that of lying down does not effect so marked a change in the latter as in the former disease; also, the modified sounds, by changing the degree of pressure of the stethoscope.
Pleural sounds are magnified during respiration; in fact, are suspended if the patient be requested to hold his breath; while in pericarditis the suspension of respiration does not necessarily impair the sounds.
Prognosis.—The prognosis is favorable, so far as life is concerned, the disease rarely terminating fatally; however, there is great danger of more or less adhesions, that leave the heart subject to more serious wrongs in later years. At times it assumes the chronic form.
In rare cases resolution is complete, the disease lasting but a few weeks. Where death occurs, it is usually the result of an intense primary disease, such as a severe croupous pneumonia, or severe chronic nephritis, or severe valvular disease.
Treatment.—The patient should be made acquainted with his true condition in order that he may the more readily acquiesce in the quietude which he will be compelled to assume to get the best results from treatment. He should occupy the recumbent position the greater part of the time, and should refrain from all conversation or reading that would tend to undue excitement.
The diet should be light, one that is readily appropriated, and given in concentrated form. Very little fluid should be allowed, no more than is absolutely necessary, and hot drinks should be entirely prohibited.
During the acute stage, to control the fever, we use the special sedatives. Aconite for the small frequent pulse, five drops to a half a glass of water, of which a teaspoonful will be given every hour. Occasionally we find excessive heart power in the early stage with a full bounding pulse; in this case veratrum ten to thirty drops to a half a glass of water, and a teaspoonful every one, two, or three hours.
Where there is a sense of weight and oppression, not due to effusion, give lobelia a half dram to a half a glass of water, teaspoonful every hour.
Bryonia.—Where there is pain of a sharp, lancinating character, bryonia is a remedy of great merit; being an anti-rheumatic and at the same time an agent whose specific action is upon serous membranes, it is doubly indicated.
Asclepias combines nicely with bryonia, especially if the skin be dry and harsh.
Macrotys will be the better remedy where there is muscular soreness; a dram to a half glass of water will give better results than the small dose. The early Eclectics accomplished better results from a decoction of the fresh root, but this is not readily obtained by the majority of physicians, and we will have to depend upon the less efficient tincture.
After the more active symptoms subside, to establish secretion from the kidneys and promote absorption of the exudate, potassium acetate, well diluted, will be a good treatment.
Digitalis, strychnia, and nitroglycerin must not be used too early, or we will overstimulate and exhaust the power of the heart, and only when the soft pulse indicates the failing power of the heart are they permissible. Cactus and crataegus, however, may be used at any stage.
When he have the history of rheumatism, the anti-rheumatics, given according to their indicated use, will prove beneficial. If uric acid be present, potassium acetate, or lithiate, should be given till it disappears. Where the patient is able to travel, change of air and climate will often prove highly beneficial, though a very high altitude should be avoided.
The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.