Pericarditis with Effusion.
Synonyms.—Sero-fibrinous Pericarditis; Hemorrhagic Pericarditis; Purulent Pericarditis.
Etiology.—This form is frequently preceded by the acute form just described, or, like the former, it follows or is accompanied by rheumatism. Bright's disease is not an infrequent forerunner of it. Tuberculosis is also a common cause, especially of the purulent and hemorrhagic variety. Septicemia and the eruptive fevers are also diseases that should be considered in the purulent and hemorrhagic forms.
In children, the disease may come on so insidiously that quite a pericardial effusion may have taken place before the physician discovers it. In such cases there is generally a tubercular taint.
Pathology.—This variety is frequently, if not always, preceded for a few days by plastic pericarditis, and is attended by the same anatomic changes; namely, a smooth, swollen, and injected membrane, in the early stage, followed soon after by a plastic exudate, usually more pronounced than in the acute form.
The pericardial layers being covered with a sticky exudate, gives the membrane a roughened appearance. This is soon followed, however, by an effusion of variable character and quantity, serum largely predominating.
If the result of rheumatism, the effusion will be serous in character; but if caused by Bright's disease, tuberculosis, cancer, the eruptive fevers, septicemia, or pyemia, the effusion will be of a lower grade, pus largely predominating, or there will be a mixture of pus and blood.
The quantity varies from a few ounces to two or three pints. With the absorption of the more fluid portion of the exudate, the lymph becomes organized, and adhesions take place, sometimes so firmly as to almost, if not entirely, obliterate the pericardial sac.
If the exudate is composed largely of pus, the myocardium presents a roughened and eroded appearance, and, being softened by the presence of pus, degeneration of its walls takes place, or there will be dilatation and thinning of its walls. Endocarditis is also a frequent result.
Symptoms.—If a primary lesion, a rare case, the symptoms common to all inflammations are present; namely, the chill, followed by fever, accompanied by a dry tongue, arrest of the secretions, increased temperature, and increased frequency of the pulse. There is nausea and sometimes vomiting. Pain of a dull, aching character is felt in the precordial region, or, if the pleura is involved, it will be of a sharp, lancinating character, extending to the back and down the left arm.
As soon as effusion takes place, dyspnea becomes the most distressing feature. If large in quantity, the left lung is burdened by pressure, and the breathing is quite labored. The right ventricle is also pressed upon, obstructing the cardio-pulmonary circulation. Although the pulse may be full and strong during the early stage, it is now small and weak, owing to pressure by the effused material.
When the disease is secondary, the primary lesion may so overshadow it that it will be entirely overlooked, especially if it follow pleurisy or pneumonia, and often the disease is not recognized till the dyspnea becomes marked, or there is effacement of the intercostal spaces; even then the disease has been overlooked and pronounced pleurisy.
In tubercular children, the disease may come on insidiously, the child growing anemic; he is of a waxy or transparent color, with a gradually increasing dyspnea, till the pericardium becomes distended with the effused fluid.
Physical Signs.—Inspection.—The skin and mucous surfaces are pale and cyanotic in appearance, and the veins in the neck are usually more distended and prominent than in health.
In the young, there will be, if much effusion, effacement, or even bulging of the intercostal spaces.
The breathing will be labored, and the patient will have an anxious expression peculiar to heart affections. The position, if lying, will be dorsal, though some will experience greater relief by lying upon the left side, thus giving greater relief to the right heart.
As the exudation increases, the upright position is assumed, with the head and shoulders thrown forward.
In the early stage, the apical beat is increased and is quite perceptible, but disappears with the presence of the effusion.
Palpation.—During the early stage, the apical beat is increased and felt in the normal position, but as the exudate appears, it becomes more feeble and is felt at a higher point and to the left, finally disappearing with the increase of the effused material.
Oppolzer taught that the apical beat changed with the position of the patient; thus if the beat had disappeared, changing the patient to the left side, or bending the body forward, would cause its return. Gerhardt, however, well says that this is not peculiar to pericarditis, as the apex beat is changed even in health by. change of position.
If myocarditis accompanies the disease, the systole is greatly enfeebled, and the apex beat disappears quite early. In case of hypertrophy, or where there are old adhesions, the apex beat may be retained throughout, notwithstanding the presence of a large quantity of effused fluid.
Percussion.—The increase in dullness depends upon the amount of effusion, the dullness assuming a triangle, the base being dependent. The dullness may extend, in extreme cases, from a half inch to the right of the sternum, to the right nipple line, and as far to the left as the axillary line, and as high as the second, or, in extreme cases, to the first interspace to the left of the sternum.
Should there be old pleural adhesions confining the lungs to the anterior chest-wall, the pericardium, with its fluid, will be carried backward, and percussion in this case would give resonance, the area of dullness being diminished rather than increased.
Auscultation.—The friction sound, already described, is heard during the initial stage, but disappears with the presence of the effusion, to return again with its absorption. The heart-beat, at first strong, becomes gradually weaker as the disease progresses, and is not due, as has generally been regarded, to the increased distance from the chest-wall by the intervening fluid, but to the weakened condition of the muscular walls of the heart, due to more or less disease of the myocardium as a complication. This view is held by Shrotter, who gives, as proof, that the fetal heart-sounds are heard through a much larger quantity of amniotic fluid than ever occurs in pericarditis.
Where the fluid is small in quantity, we may hear the murmurs due to endocarditis, when this complication exists.
Diagnosis.—This disease is often overlooked, owing to the primary lesion; but if a careful examination is made, it can be recognized by the characteristic friction rub in the early stage, and the triangular area of dullness, extending in severe cases to the first interspace.
The pericardial sound is a rough, grating noise near the ear. The endocardial sound is blowing, and distant from the ear.
We recognize it from pleurisy by the absence of the sharp, lancinating, stablike pain characteristic of pleurisy, and also by the cessation of the friction sound during a momentary suspension of respiration, the friction sound continuing in pericarditis without regard to respiration; from cardiac dilatation, by the history of rheumatism, of the former, also septic or infectious diseases, and the presence of pain in the cardiac region. In cardiac dilatation there will be a history of heart disease, an absence of fever and pain, and there will be no friction sound in the latter.
Prognosis.—The prognosis in this form must be guarded; for while some cases are so mild as to pass unnoticed, others are so severe as to prove fatal in a few days. In mild cases, the disease may terminate favorably within a week or two, all evidence of inflammation disappearing, and the effusion of serous material be entirely absorbed in the course of two or three weeks. When the disease is the result of scurvy or pyemia, death may occur in forty-eight or seventy-two hours.
The condition of the heart must also be taken into consideration in the prognosis. If the heart be in good condition—that is, if there be no structural change—the prognosis will be favorable, but just in proportion as degenerative changes take place' will the outcome be unfavorable.
If endocarditis complicate the disease, valvular lesions are almost sure to exist, and this always renders the disease more grave, as does dilatation of the heart.
The cause giving rise to the disease must also be taken into consideration in making a prognosis; thus septicemia, scurvy, Bright's disease, and the infectious fevers give rise to a more grave form than rheumatism.
The character of the effusion also determines to a great extent the gravity of the ca'se. Thus, if serum alone is the product, the case may be hopeful; but if it be purulent or hemorrhagic, the outlook will be unfavorable.
Treatment.—In the early stage the treatment will be the same as for the plastic form; namely, absolute quiet, and the avoidance of everything that would irritate or excite the patient. The indicated sedative, and bryonia, asclepias, macrotys, or lobelia will be given, as the case may require. Spigelia will be useful during this stage, where there is a sharp, stabbing pain, accompanied by great oppression and undue anxiety. As the disease progresses and the effusion becomes more pronounced, we rely upon such remedies as give tone to the overburdened heart and stimulate the absorbents to carry off the accumulated fluid. Strophanthus influences the heart favorably when given in the small dose, and at the same time excites the kidneys to greater secretion. To a half glass of water add ten or twenty drops. of the tincture, and give a teaspoonful every one, two, or three hours.
Apocynum.—Of the many remedies recommended for cardiac troubles, however, I know of no remedy in the materia medica equal to that of apocynum, especially with effusion in the pericardium. The action is similar to that of digitalis, but it is not cumulative. The cardiac impulse grows stronger, the dyspnea becomes less, palpitation disappears, and, through its influence on the kidneys, diuresis is greatly increased. If given in large closes, it produces copious watery stools, and, where the patient is not feeble, this action is not undesirable. If the specific tincture be used, add from ten to thirty drops to a half glass of water, and give a teaspoonful every hour. If you do not secure satisfactory results from this, then use the decoction, made from the fresh root. To two ounces of the crushed root, add ten ounces of water, and reduce one-half; two hours or more should be occupied in its preparation. Strain and add sufficient alcohol or glycerin to prevent fermentation; of this, commence with five drops, gradually increasing the dose as the stomach will tolerate it, till you reach the maximum dose, one teaspoonful, which may be given every four or five hours. Some patients can not take over ten drops at a dose, the remedy being exceedingly bitter and somewhat nauseating. In dropsies of the heart it has no superior, and I very much question if it has its equal.
Apocynum is also an anti-rheumatic, and where there is edema of the joints it is doubly indicated.
Digitalis.—Where the heart's action is very rapid and feeble, digitalis in the small dose will give good results.
Where rheumatism has been a marked feature in the case, and if there be muscular soreness, macrotys should be used. The early Eclectics obtained great results from the decoction, and where the fresh root can be secured it will often give better results than the tincture, though in most cases the tincture will not disappoint. The dose of the latter will be twenty to thirty drops in a half a glass of water, a teaspoonful every two, three, or four hours.
Cactus.—Where the heart's action is feeble, cactus should be given. This may be alternated with any of the above-mentioned remedies. Where the effusion is very great, causing great dyspnea, and the patient takes on a cyanotic appearance, para-centesis should at once be performed. The fourth interspace near the sternum is the point to be selected. If the patient be very feeble, not more than two or three ounces should be removed at the first operation, more being withdrawn a few days later.
If the effused fluid be of a purulent character, echinacea, baptisia, the chlorates or mineral acids, would be used according to special conditions as expressed by the tongue. Should the effused material be especially offensive, free incision has been recommended and a free drainage established.
The patient should be given nourishing food. though fluids must be restricted to as small amount as is compatible with health. During convalesence, the patient should avoid anything of an exciting nature, and be careful not to do anything that will overtax the heart.
The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.