DISEASES OF THE HEART - history of the various conditions of disease of the heart must of necessity present extreme contrasts, as they are calculated to interfere very greatly or not at all with the general comfort and well-being of the patient. Commencing as some do in the most gradual and imperceptible manner, a long period elapses in their history during which they are utterly unsuspected by the patient, and may be only casually discovered by the physician : by-and-by they begin to interfere with the circulation, and conse quently with the breathing, and the patient becomes short-winded, or, as he supposes, asthmatic ; and then an educated practitioner readily traces the true cause of the symptoms. In another set of cases a sudden strain is put upon the diseased organ, which over powers its imperfect action, hitherto unrecognized, and irregular contraction, labored movement, and impeded circulation at once develop themselves, and are assumed to be the commencement of disease in the narrative of the patient. Not unlike these last are a few rare cases, in which the strain has been so great as to rup ture some part of the delicate mechanism in states of perfect health, and to have been in reality the beginning of the disease. In yet another class we are able to trace the history of inflamma tory action by pain and dyspncea in recent cases, or by the account of circumstances likely to have excited it, in those of long stand ing, and by the continuance of disordered function since the pri mary ailment.
We thus divide the cases naturally into the acute and chronic diseases of the heart; the one forming only a very small section, exceedingly limited as to the causes of their existence ; the other embracing by far the larger number of cases, which can be traced back either to partial recovery from an acute attack, or to a variety of other causes, some of which are very vague and ill-defined.
Among the acute cases we find pain or dyspncea not unfre quently present ; among.the chronic they are unusual, at least as a permanent condition, and when met with, sometimes assume the characters which have been ascribed to angina pectoris. (Chap. XVI. § 4.) The dyspncea of inflammation may be spoken of rather as a catching in the breathing, or feeling of anxiety con nected with it ; that of chronic disease is more decidedly what patients call "shortness of breath," felt in running, in going up stairs, &c. The character of the pulse of course very often offers direct evidence of disease of the heart : and, in addition to this, the presence or history of rheumatic fever, of inflammation of the pleura, of disease of the kidney and of dropsy, as the more con stant associations of acute or chronic disease of the heart, are each to be viewed in the light of symptoms, or at least indications of its presence. Among them all, that which leads most frequently
to the detection of cardiac inflammation is the presence of acute rheumatism.
§ 1. Pericarditis.—If any of the signs of those diseases just mentioned as being associated with cardiac inflammation be pre sented to our observation, and if, on examination of the heart, pericardial friction be made out, there can be no doubt that peri carditis exists : other indications of inflammatory action will not be wanting, but here there is less need for the evidence of corre lative symptoms than in other cases. When friction-sound is absent, it may be annulled either by the presence of fluid, or by universal adhesion ; in either case, the general symptoms must be decided before we can be warranted in pronouncing such a diagnosis. Along with these, not in opposition to them, we shall find in the former very extended dulness, especially in an upward direction, and, as usually described, assuming somewhat of a pear shaped form ; undulatory movement may sometimes be visible over the prtecordial space, while the heart's action is excited; labored, or irregular, and the apex-beat somewhat elevated ; the ordinary sounds of the heart are distant and indistinct over the position of percussion dulness, becoming louder and more natural above the space occupied by the fluid ; tenderness over the prte cordial space, pain, and dyspno3a, and great distress from any sudden movement, are also met with in such cases. On the other hand, when the surfaces are agglutinated together, the evidence is more obscure ; perhaps the most important points, when taken in connection with the general symptoms, are persistently per verted rhythm with nothing else to account for it, and a certain degree of obscurity of sounds, accompanied by increased and excited action. When along with these there are also prEecordial pain, distress or anxiety, and dyspncea, the diagnosis may be pretty certain in a case of acute rheumatism ofsevere pleurisy, where pericarditis is to be looked for but can never be relied on when there is nothing else to guide us to it.