While circumscribed inflammations of the pericardium, especially those which occur with heart lesions in children, may appear and dis appear without symptoms, other forms, with recurrent severe attacks of articular rheumatism, a characteristic course, with eccentric hypertrophy of the heart which develops rapidly, asystolia, marked pain, great pallor and stenoeardial attacks. Death front pericarditis in childhood rarely occurs with the appearance of dropsy.
Pericarditis is the tnost serious complication of rheumatism in childhood. Cadet de Gassicourt rightly says that all children who are killed by rheumatism die from pericarditis. While the mortality rate of rheumatism in adults is 3 to 4 per cent. (Besnier), this reaches 6 per cent. in children (Cadet de Gassicourt), and only on account of its being complicated by pericarditis.
diagnosis of pericarditis in children has been covered essentially in the presentation of the symptomatology of this disease. Only the differential diagnosis between pericardial effusion and acute dilatation of the heart requires some words, especially as both conditions occur frequently with the same disease, scarlet fever. In both conditions the cardiac dulness is increased, the apex-beat weak ened or absent, the heart sounds dull and faint. Here Pins' symptom and the return, with change of position, of the apex-beat which had disappeared, may sometimes decide in favor of pericarditis; yet it must not be forgotten that the last-mentioned sign may be absent in peri carditis, if adhesions have formed between the pericardium and the heart.
It is not, as a rule, difficult to recognize the nature of the exudate. The simultaneous occurrence of pyannic symptoms points to a purulent effusion, while the exudate after rheumatism is usually serofibrinous.
The pericardial friction murmur, at the beginning of the disease in children, is very commonly purely systolic. In early childhood it is often so soft that it is easily mistaken for an endocardial murmur; yet it is not transmitted beyond the precordial region and its point of maxi mum intensity is not at the apex, as in acute mitral endocarditis of children.
In small children with slight purulent pericardial effusion, physical signs may be wholly absent. Sometimes thc presence of most severe cardiac weakness which cannot be explained by the other symptoms may lead to the probable diagnosis of purulent pericarditis.
prophylactic and causal treatment of pericarditis in children may be mentioned. The physician should alw-ays give his full attention to rheumatic symptoms in childhood and should never be satisfied with the inconsiderate diagnosis of '' growing pains" when older children complain of pain in the joints and muscles. In the majority of these cases rheumatism is masked and the treatment with salicy lates may offer protection to the heart. The same thing is true of choreic and scarlatinal pains in the limbs of children.
Whether the treatment with salicylates should be continued when rheumatic pericarditis has developed depends upon the state of the car diac muscle. Dry pericarditis should always be treated with salicylic preparations at the beginning. To small children one or two grams of sodium salicylate, aspirin, salipyrin or salophen are given daily; double this dose to older children. Inunctions of the precordial region with salicylic preparations, such as inesotan or rheumasan are of value when the stomach will not tolerate salicylates internally.
An unconditional therapeutic requi.site is absolute rest, with the application of cold to the precordial region (best done by using small tubes through which cold water runs). Symptoms of cardiac weakness must be treated according to the rules given on page 527.
In chronic effusions the external application of preparations of iodine (tincture of iodine, iodvasogen) may be tried. Mercurial oint ment may be employed interchangeably with preparations of iodine. Very large exudates, which permit of no other treatment, must be evacuated by surgical intervention; here it should be noted that punc ture is as a rule an inadequate procedure, while incision, laying the pericardium widely open, with resection of the ribs and establishing drainage but avoiding irrigations, fulfils all indications.
Puncture, which, performed with caution, should be an exploratory puncture with a hypodermic syringe, is to be done in the fifth or sixth intercostal space. It sometimes saves life (cases of Biedert and Jiirgen sen) but it in no way hinders the reaccumulation of pericardial effusion. Incision has frequently lead to permanently successful results in children (Rosenstein, West, Dickinson, Sievers) and is as a rule performed in the sixth intercostal space near the sternum.