=Pericarditis= is an inflammation of the serous membrane covering the
heart and its reflection in front over the chest. Primary inflammation
of the pericardium is rare. Such cases usually result from cold and
exposure or injury or tuberculosis, and are most commonly met with in
children.
The exciting causes of =secondary pericarditis= are rheumatism,
Bright’s disease, tuberculosis, gout, diabetes, eruptive fevers,
various septic conditions and dyscrasia. Pericarditis may result by
extension of inflammation from contiguous organs, as the disease may
occur in pneumonia, pleuropneumonia, chronic valvular diseases, and
ulcerative diseases of the esophagus, bronchi, vertebræ, ribs, stomach,
etc.
Displacement of the ribs over the heart and involvement of the
corresponding vertebræ predispose to pericarditis, by weakening the
innervation of the pericardium and thus disturbing the circulation.
Lesions of the cervical region affecting the left phrenic are to
be considered. Upper rib lesions may disturb the internal mammary
artery and the lymphatics, which have important relationship with
the pericardium. The disease may occur at any age. Males are more
frequently attacked than females.
The morbid conditions vary with the stage. The stages are (1) acute,
plastic, or dry pericarditis; (2) pericarditis with effusion,
serofibrinous, hemorrhagic or purulent; (3) absorption or adhesive
pericarditis. These different stages or varieties commonly succeed one
another, although medical writers place so much importance in them that
each is described separately. =Acute pericarditis= is by far the most
common and often the inflammation subsides at this point instead of
going on to more serious involvement. There is a possibility that in
some cases the forms are independent of each other.
The changes are the same as in various serous membranes. Hyperemia
and alteration of the epithelium is most marked on the visceral
layer. This is followed by an exudation from the hyperemic vessels.
There is roughening and loosening of the epithelium and the fibrin is
precipitated upon the walls of the pericardium. More or less lymph is
exuded and sometimes injected capillaries burst and cause a bloody
exudation. From this stage the morbid appearances vary according to the
progress of the disease. The disease may undergo resolution and fatty
degeneration and absorption of the products in point take place. As
the stage of effusion occurs, the parietal and visceral layers of the
pericardium are separated by a serofibrinous exudate. This condition
may increase until the quantity of the exudation is considerable,
or the effusion may become absorbed. Rarely does the exudate become
purulent.
Adhesions may be formed between the layers of the pericardium, during
the last stage, by bands of various lengths or the layers are more or
less separable.
=Symptoms.=—Simple cases may not present any symptoms. Usually a chill
or cold feeling at the heart, followed by pains in the cardiac region,
ushers in the attack. Fever is commonly present, rarely exceeding 103
degrees F. Tenderness over the heart is noticeable. There is dyspnea
and the patient is restless.
In the =effusive stage= the symptoms depend largely upon the amount
of diffusion. The pain is sharp and stitch-like. Nausea, vomiting and
hiccough sometimes occur. The pulse is irregular and feeble. Insomnia,
headache and even delirium may occur. Distention of the veins of
the neck may cause dysphagia and a cough may be present, owing to
the irritation of the trachea. The recurrent laryngeal nerve may be
compressed as it winds about the aorta and thus cause aphonia.
The friction sound is a characteristic physical sign of the first
stage. In the effusive stage there may be precordial bulging. The
area of dullness is enlarged, the diaphragm and liver may be crowded
downward, causing an epigastric bulging. As the effusion increases, the
heart sounds become less distinct; the friction is not heard. In the
=third stage= there is usually a return to normal, although =adhesions=
may form and cause precordial retraction and permanently embarrass the
heart’s movements. The young are more subject to permanent disability.
Extension of heart impulse, which is undulatory; diastolic shock
to hand placed over heart; increased area of dullness; prominent
precordia; position of patient does not change apex beat; and when
pericardium is adherent to diaphragm a systolic tug is noted over
points of attachment, are essential signs and symptoms.
=Diagnosis.=—Pericarditis is frequently overlooked. It is a serious
disease and one should be especially careful. In cases of rheumatism
the osteopath must always be on his guard. Tonsillitis may be the
origin of the infection. Care has to be taken in distinguishing
between dilatation and cardiac hypertrophy and pericardial effusion.
Hydro-pericardium may be mistaken for pericardial effusion.
To distinguish between endocarditis and pericarditis should not be
a difficult task if one understands thoroughly the nature of each
disease. A large pericardial effusion may be confounded with a pleural
effusion. In doubtful cases utilize the X-ray.
=Prognosis.=—In mild cases of pericarditis the large majority rapidly
recover in two to three weeks. In cachectic subjects and where
adhesions have formed, the duration is longer. Relapses may occur. The
purulent effusions are always serious.
=Treatment.=—Demands prompt and effective measures. Absolute rest
mentally and physically, is necessary. Too much stress cannot be
laid upon this point, as death has occurred from neglect of this. To
quiet the heart’s action is the first necessary requisite, and then
give treatment to limit the inflammation. In the early stage relaxing
the upper dorsal musculature to control innervation, and raising and
freeing all the upper ribs and clavicles to promote lymphatic drainage
is effective. In the second stage prevention of cardiac failure and
promotion of absorption are the indications to be met. Too much
importance cannot be placed upon the point that general strength,
good nursing, dieting and free elimination are essential, not only in
securing a rapid subsidence of the inflammation, but to prevent further
complications.
Raising and separating the ribs over the heart will be of great aid
in lessening the inflammation and promoting absorption. In many cases
lesions to the ribs on the left side and subdislocations of the
vertebræ affecting the vasomotor nerves, the lymphatics and nerves to
the heart will be found. The first five ribs and corresponding vertebræ
is the region where one may expect to find the lesions. In addition to
absolute rest, an inhibiting treatment in the dorsal region between
the scapulæ will aid in slowing the heart’s action. Correcting any
lesion that may be found to the vagi nerves will also be a help in
controlling the heart’s action; besides, most of the vasomotor fibers
to the heart are in the vagi. These lesions are usually found at the
atlas. One should also examine carefully all the cervical vertebræ for
derangements that might affect the cervical sympathetic, especially
the superior and middle cervical ganglia. These ganglia are primarily
affected from the fifth cervical to the first dorsal. Inhibition for
a few minutes between the transverse process of the atlas and the
occipital bone to the posterior occipital nerves will be of great aid
in controlling the tumultuous action of the heart; also, inhibit in the
upper dorsal. The warm bath will quiet the heart, but care should be
taken not to weaken the patient. The general treatment has the effect
of lessening nervousness and quieting the heart.
The function of the phrenic nerve must be borne in mind when regarding
the pericardium. The phrenic is usually primarily affected at the
third, fourth and fifth cervicals, and occasionally there are
connecting fibers as low as the fourth and fifth dorsals. Ice-bags may
be found of value in retarding the progress of the effusion and in
lessening the heart’s action. Liquid food, as milk and broths, should
be given throughout the disease. If the effusion is very large the
services of a surgeon should be secured and tapping performed. If the
effusion is of a purulent nature, a free incision should be made with
antiseptic precautions.
In chronic cases carefully graduated breathing exercises and moderate
stretching of the adherent regions, if pathology permits, should be
considered.