Decided value in the diagnosis, however, in childhood especially, is attached to the functional disturbances caused by pericardial adhe sions. The tendency of the heart to contract and to grow is hindered by the obliteration of the pericardium. This leads to symptoms of pulse weakness and cardiac insufficiency which increase with advancing age. In conformity with this, pericardial adhesion frequently causes death, even in childhood. Indeed, it can be said that most of the causes of death from the acqttired heart affections of children are due to the addi tional occurrences of pericardial adhesion. The most severe congenital and acquired heart lesions, even whim several conditions are associated, may be well borne for years during childhood, thanks to the extraor dinary compensatory ability of the musculature of the child's heart; but as soon as obliteration of the pericardium is added,—and this some times develops wholly latently,—symptoms of congestion and adema appear which lead to death.
Tuberculous adhesions of the pericardium sometimes run the course apparently of an increasing dilatation of the heart, characterized by small pulse, weak apex-beat, palpitation and oedema. When these symptoms have lasted a long time, if tuberculous processes are discover able on the other serous membranes. the differential diagnosis of tuber culous symphysis pericardii is made possible, as opposed to dilatation of the heart. Sudden death from cardiac insufficiency has been seen in older children with this condition (Schtineich's case, a boy of 8 years).
Pericardial adhesion is relatively more frequent in childhood than in adults. According to Marian, the two chief forms of this condition, rheumatic and tuberculous, are differentiated from the contrasting relation of the volume of the heart which is decidedly increased in the former and small in the latter. Rheumatic symphysis pericardii is as a rule associated with valvular changes. while the tuberculous form is not. Both forms end fatally with symptoms of myasthenia. The investiga tions of Hutinel, F. Pick and illoizard have made clear the intimate relation between hyperplasia of the liver and obliteration of the peri cardium, and the twofold reaction of the liver in the forms of pert hepatitis and a sort of cirrhosis has been shown. In the tuberculous form especially, in which cardiac symptoms are frequently totally absent, a condition arises which might easily be mistaken for tuber culous peritonitis or alcoholic cirrhosis of the liver.
Diagnosis. —The diagnosis of adhesion of the pericardium is only made with certainty if that portion of the heart lying further to the left side is drawn inward regularly with each systole. The diagnosis is the more certain if the heart is not excessively large, in which case a systolic sinking-in of the intercostal spaces is not rare, even though the force exerted in this in-sinking is decidedly less than that noted when the whole chest wall is drawn in with adherent pericardium. Almost always, too, the in-drawing of pericardial obliteration is followed by a diastolic rebound of the parts of the chest wall previously drawn in (seen even more plainly in children than in adults), a thing which never occurs with simple cardiac hypertrophy.
The appearance of pulsus paradoxus (disappearance of the radial pulse during inspiration) and inspiratory distention of the veins of the neck (Kussmaul) are uncertain symptoms which depend upon compression of the large blood vessels by mediastival callosities. The same thing is true of Friedreich's diastolic collapse of the jugular veins which, as is well known, also occurs with tricuspid insufficiency and widely open foramen ovale.
In later childhood obliterating pericarditis is sometimes one of the symptoms of chronic sclerotic, often tuberculous processes, of the various serous membranes, in which the peritoneum, especially that portion covering the liver, is must frequently affected (sugar-crusted liver). When this is associated with symphysis pericarclii, ascites may appear early, a condition which is sometimes of diagnostic value in the recognition of this general disease of the serous membranes.
Treatment.—When the adhesion has reached the fibrous stage all treatment is useless. Whether separation of the pericardial adhe sions surgically, as has already been attempted in later life, will prove of value in childhood remains undecided. In early life especially, when arrested cardiac growth is most important, freeing the heart of its constricting bands and callosities would be doubly valuable. In the rheumatic form of pericardial obliteration, as long as attacks of rheu matism still occur, the administration of salicylatcs is indicated, as in pericarditis. The treatment of the symptoms of insufficiency of the cardiac musculature is given on page 527.