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stage, pericardium, symptoms, inflammation, increased, lymph and sound

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In subacute pericarditis the subjective symptoms are less marked. There may be no more than a sense of uneasiness about the heart, with some increased rapidity of its action.

In mild cases there may be no subjective symptoms whatever- nothing but the pericardial rub to point out the existence of the dis ease. In not a few such cases the inflammation is limited to that portion of the membrane which surrounds the great vessels at the base of the heart, and may give rise to no symptoms during life. In the post-mortem room this very limited form of the malady is often found in those who have died of some other complication. Not un likely it is an extension to the pericardium of inflammation originat ing in the subjacent fibrous rings.

The earliest stage of acute inflammation of the pericardium con sists in hyperaemia of the membrane. It cannot be said that this stage has any specially characteristic symptoms or physical signs. But in very acute cases it may be accompanied by increased vigor and energy of the heart's action. Without producing any bruit this increased vigor imparts to the first sound of the heart an exaggerated ring or tone, which may be sufficiently marked to enable us to sus pect, if not actually diagnose, commencing inflammation of the peri cardium. This "tension sound," as it has been called, may be re garded as the earliest objective evidence of the onset of pericarditis. It is only in acute cases that it is observed: and in them the first stage of the disease, during which alone it is heard, lasts for so short a time that this sign readily escapes detection. When observed, it is soon thrown into the background by the more striking and important indications of the following stage.

The second stage comes in quick succession to the first. It is characterized by the effusion of lymph, and the formation of a fibrin ous layer of new material on the surface of the inflamed membrane.

It is at this period that the signs and symptoms of the disease come to the front, and that its existence is generally diagnosed. The new material which is formed on the surface of the pericardium pro duces a marked alteration there. Instead of a smooth glistening sur face allowing the visceral to glide gently and easily over the parietal portion of the membrane, there is a coating of lymph which is so soft that its surface gets roughened by the rubbing to which it is sub jected, and becomes more or less ragged and shaggy in appearance.

The rubbing against each other of the thus roughened surfaces of the pericardium produces the "to and fro" friction sound characteristic of the disease. This sound is generally double, but may be single, and then is usually short, and may be with difficulty distinguished from an endocardial blow. It is generally heard first near the base of the heart, but it may be distinct over the whole organ. It is superficial in character, like a pleuritic rub, but easily distinguished from that by its situation, and by its being independent of the respiratory movements. There is no increase of cardiac dulness. This is the stage at which any subjective symptoms which may exist are usually felt.

The morbid process may go no further than this. The inflam mation may decline, the lymph may be reabsorbed, and the pericar dium be restored to its natural state; or the two roughened surfaces may adhere together to a greater or less extent.

In acute cases there is generally a third stage, characterized by the effusion of serum into the sac of the pericardium. A certain amount of fluid is thrown out during the second stage at the same time as the lymph. The quantity may be so small that it gives no physical evidence of its existence, and is quickly absorbed when the inflammation subsides. The presence of a larger quantity gives very decided evidence of its existence. It separates the visceral from the parietal layer of the pericardium. Rubbing of the surfaces against each other thus becomes impossible, friction ceases to be heard, and any pain which there may have been disappears. The area of car diac dulness is increased. If the sac of the pericardium be quite full, the region of dulness has the triangular shape of that sac—with the apex above and the base below. The dulness extends to the left of and beyond the apex point. The heart's impulse is not felt as in hypertrophy of the organ. The sounds are distant and indistinct. The pulse is quick and feeble—may be irregular. There is increased frequency of respiration, and the patient may be in considerable distress.

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