PERICARDIUM, DISEASES OF THE. Pericarditis.
Definition. — Inflammation of the serous covering of the heart, the result of primary or secondary infection.
Symptoms.—The subjective symptoms may vary greatly in severity. In mild cases the disease may call no attention to itself, and its discovery can only be made, if at all, by means of careful physical ex amination.
In severer cases there is uneasiness or pain in the cardiac region, with moderate fever and a general feeling of bodily dis tress. An important symptom is short ness of breath. There may also be palpi tation, tenderness of the prmcordial re gion, and a dry cough. As fluid accumu lates in the prwcordial sac, the symptoms change correspondingly, the heart's ac tion being more embarrassed (especially its diastole), the dyspncea and sense of anxiety increasing, yet pain, on the other hand, diminishing. In young children pain is usually absent. It has been stated that the pain is greater in pericarditis with effusion than in merely fibrinous pericarditis. This statement applied, so far as regards cases with effusion, to the time before the effusion develops.
The pulse at first is apt to be rather forcible; in later stages it becomes irreg ular, intermittent, and of low tension. The disturbance of cerebral circulation is shown by wakefulness, headache, and in severer cases dullness, delirium, or even melancholia. Rare complications are chorea and epilepsy.
Great distension of the pericardial sac may occasion dysphagia, which may be lessened if the patient is raised into a sit ting posture or bends forward. Some times the difficulty in swallowing appears to be due merely to nervous disturbance. There may likewise be vomiting, of nerv ous origin, because of irritation of the recurrent laryngeal nerve. Balfour warns us that the occurrence of delirium in the course of rheumatic fever ought at once to direct attention to the heart.
As regards objective symptoms, the dis ease may, as already said, run its course without directing the patient's attention to its existence; likewise the disease may escape the persistent and assiduous efforts of the physician to discover it. In gen
eral appearance the patient is apt to be anxious, distressed, and of a dusky coun tenance.
Before any effusion has accumulated in the heart-sac there may be tenderness on friction over the cardiac area; there is not apt to be great enlargement of the heart, although it may become somewhat dilated. In the early stages of the dis ease the heart's impulse is somewhat ex aggerated, but later it becomes feeble. The veins of the neck may be distended or may even display pulsation. If there is considerable effusion, the prwcordia may be somewhat prominent, especially in children, and the intercostal spaces raised so as to be on a level with the gen eral surface. Sometimes the affected re gion exhibits oedema, particularly when there is pus.
On palpation it may be possible to de tect friction. The apex-beat may be felt in its normal condition. As an effusion collects, the apex becomes less easily palpable, and finally disappears. Some times, however, it will be discovered if the patient can bend forward, thus caus ing the heart to approach again more closely to the chest-wall.
Gibson states that "the vocal fremitus over the sternal region loses some of its intensity, and even fluctuation has been observed." As fluid collects in the sac, the area of cardiac dullness increases in every direction. The classical descrip tion of the shape of the dull area is that it resembles a triangle, or a pear hanging by its stem, with its base at the lower part of the chest. These shapes are more often exhibited by large than by mod erate effusions. The extension of the dullness upward and to the right is quite constant. It is possible that adhesions may modify the position of the fluid. Sears, for example, mentions a case in which the heart -lay against the anterior chest-wall, and about half a pint of pus had collected behind the organ.