and muffled, though generally less so than in effusions of fluid into
the pericardium. They may be very faint; at least the first sound may
be, on account of the degeneration of the walls of the heart, and
murmurs may exist from attending valvular lesions. The sounds of the
heart may be reduplicated. Skoda and Friedreich laid great stress on
this. But reduplicated heart sounds are not pathognomonic of any
affection.
It has been stated that partial adhesions may exist in such form as not
to prevent the free surfaces of the pericardium from rubbing against
each other, and friction sounds will result, but as the adhesions
become general these sounds will disappear.
The cardiac percussion dulness is but slightly increased unless there
be also hypertrophy or dilatation. The area of cardiac dulness is
lessened during inspiration, because the anterior margins of the lungs
extend nearly to the middle line over the front of the heart. This is
so even in pericarditis with adhesions, unless the adherent pericardium
be attached to the front of the chest and the pleura be also adherent;
then the area of absolute dulness remains unchanged during the
respiratory acts.
The cardiac impulse will be found at times to be increased by the
traction of the adhesions in the pericardium and adjacent parts; at
others the impulse is diminished. A disproportion between the marked
beating of the body of the heart against the chest-walls and the feeble
impulse of the apex has a diagnostic significance--one much greater
than a double impulse. The point of cardiac impulse mostly remains
unchanged. A depression at and near that point, noticeable during the
systolic action of the heart, is among the more certain of the signs of
adherent pericardium. When the adhesions extend to the pleura, this
systolic dimpling is greater, and becomes often very marked; and it is
questionable whether it occurs to any extent without pleural adhesions
also existing. Often the apex-beat of the heart does not change {788}
with the change of position of the patient. The chest remains normal in
shape unless altered by extensive and strong adhesions to the adjacent
parts. Under such circumstances there is depression of the fifth and
sixth intercostal spaces, the epigastrium is sunken, and the sternum
and cartilages are flattened or drawn in; this becomes most apparent
during the systole of the heart. The inspiratory bulging is greatest on
the right side in consequence of the fixation of the diaphragm.
Hypertrophy or dilatation and valvular disease, if associated with
adherent pericardium, modify of necessity both the signs on percussion
and auscultation. The aortic and mitral valves are the ones
particularly affected. It is when these complications exist, rather
than merely from the pericardial adhesion, that we find more or less
dyspnoea or orthopnoea and a sense of faintness and dizziness, an
anxious expression of countenance, imperfect aëration of the blood,
lividity of the lips, dropsy, and difficulty of swallowing.
There is much uncertainty in the DIAGNOSIS of partially adherent
pericardium; for the friction sound may be present, the impulse normal,
the heart's action unrestrained, there may be no impeded respiration,
and the patient may present none of the physical signs of adhesions.
Indeed, under any circumstances the diagnosis of adherent pericardium
is not a very trustworthy one. More than one of the physical signs
mentioned must exist to warrant anything like a positive opinion, and
the disease may be latent.
William H. Webb[30] has recorded a case of complete obliteration of the
pericardial sac by inflammatory adhesions, associated with enormous
hypertrophy of the heart and valvular disease, in which there were no
symptoms nor physical signs to lead to a suspicion of the true state of
things.[31]
[Footnote 30: I take this opportunity of acknowledging the valuable aid
I have received from Dr. Webb in preparing this essay on affections of
the pericardium.]
[Footnote 31: _Philadelphia Medical Times_, vol. ii.]
The PROGNOSIS of adherent pericardium depends rather upon the secondary
consequences, upon the condition of the muscular walls, the
hypertrophy, the dilatation, the coexistence of valvular disease, than
upon the adherent pericardium itself. Yet there is a tendency to sudden
death caused by it. In 115 instances of sudden death, Aran has recorded
9 of complete pericardial adhesion.
The TREATMENT must be that of the consequences with careful attention
to the state of the muscular walls. Digitalis is indicated in cases
with dilatation and flabby walls. Early in the case repeated small
blisters and a course of iodide of potassium may be tried. But it is
doubtful whether any useful result will be accomplished.
Hæmopericardium.
Hæmopericardium, or blood or blood and serum in the pericardial cavity,
is rarely met with except as a result of rupture of the heart, injury
to the pericardium by perforation or crushing, aneurisms, and in
pericarditis occurring in diseases of a low type with degeneration of
the blood, as in scurvy and purpura hæmorrhagica.
In rupture of the heart the effusion of blood into the sac is rarely
rapid, and death is not immediate unless the rupture be large. Rapid
distension of the pericardium with blood speedily causes death by
embarrassing the action of the heart and by producing anæmia of the
brain. Thus the rupture of an aneurism into the pericardial sac is of
necessity quickly fatal. Penetrating wounds may be the cause of a
bloody accumulation in the pericardium and give rise to serious
symptoms. But the injury is not always fatal, since large vessels are
not likely to be cut; the {789} hemorrhage is slow, thus permitting the
pericardium to accommodate itself to the fluid; and if the amount of
blood be not very large, it may be ultimately absorbed. Crushing
injuries to the chest may produce effusion of blood into the
pericardium by lacerating small vessels, and may burst the coronary
arteries if they be diseased. The foregoing are traumatic causes; the
true hæmopericardium is due to the effusion of blood or blood and serum
in diseases of malnutrition and in dyscrasias which have special
tendencies toward the serous membrane, particularly to the pericardium.
This does not take note of the bloody effusions or of a certain amount
of blood in the serum which may occur in the course of acute
pericarditis; but rather of those diseases, such as scurvy, purpura,
and chronic alcoholism, in which the blood is broken down, the tissues
weakened, the degenerated vessels rupture or are no longer able to
contain their contents, and in which the blood or bloody serum
accumulates speedily in the pericardium, without or with but slight
previous inflammation.
The physical signs of hæmopericardium are the same as in other
effusions into the sac, with this difference--that in the traumatic
kind the area of cardiac dulness is rapidly increased, while at the
same time the fluid never reaches the bulk of other effusions, for
before this can happen death occurs. Friction phenomena are not
perceived. There are as symptoms dizziness and faintness, drowsiness,
difficulty of breathing, sense of præcordial oppression, weak pulse,
and, when myocarditis exists, pain in the heart. The prognosis
generally is unfavorable. Death, if not the direct result of the causes
producing hæmopericardium, is due to the hemorrhage or to failure of
the heart.
The TREATMENT consists in absolute rest, in giving readily-digested
food, and in supporting the action of the heart; for this purpose
stimulants may be required, unless something in the history of the case
forbid. Of course it will also be important to keep the emunctories,
especially the kidneys, freely at work, and to modify the condition of
the blood in the cases associated with dyscrasias. The mineral acids
and ergot are remedies to be borne in mind.
Hydropericardium.
Hydropericardium is the presence of serous fluid in the pericardium of
greater quantity than the normal, not dependent upon inflammation--a
pericardial dropsy. To constitute this it must be more than an ounce or
two; it must be sufficient to be recognizable during life.
The fluid in hydropericardium very rarely reaches the extreme quantity
effused in pericarditis. It is alkaline in its reaction and of a pale
straw color, or it may be of a deeper yellow and opaque, the color and
opacity depending upon the presence of hæmatin, biliary coloring
matter, and epithelium. It is chiefly water. According to the analysis
of Gorup-Besanez, there are of water, 95.51; albumen, 2.46; fibrin,
0.08; organic matter, 1.27; inorganic salts, 0.95.
Hydropericardium is apt to occur in conjunction with dropsies in other
parts, particularly with hydrothorax. It may be the result of local
stasis in the veins and lymphatics of the heart and pericardium or of
neighboring parts; or it is more usually the sequela, forming part of a
diffused dropsy, of certain general diseases, as of the exanthemata,
particularly scarlet fever; or is the accompaniment of Bright's disease
of the kidneys; or of obstructive diseases of the liver; or of
affections of the thoracic viscera which impede the circulation of
blood through the heart and lungs. The walls of the heart become soft
and flabby, and are consequently weakened; the circulation in the
coronary arteries and veins is sluggish.
It is almost invariably a chronic affection, coming on insidiously, and
its {790} existence may not be suspected until the disorder is well
advanced, when some symptom, suddenly developed, directs attention to
the heart.
After death the serous pericardium is found to be opaque, somewhat
thickened, and to have an anæmic appearance. The opacity is due either
to interstitial deposit or to the swelling of the epithelium.
The DIAGNOSIS of hydropericardium is surrounded by similar difficulties
to that of pericardial effusion. It presents the same physical signs as
this disease, except the friction at the base, and can only be
distinguished by the history of the case and the attending general
features.
The PROGNOSIS depends upon the extent of the dropsy and the cause
producing it; in point of fact, more upon the latter. The prognosis is
apt to be unfavorable when the disease is occasioned by any of the
exanthemata or by Bright's disease.
The TREATMENT is that of the disease occasioning it and of the dropsy
of which it forms part.
Pyopericardium.
Pus may accumulate in the pericardium as a result of pericarditis, and
this has been already described. Further, metastatic or pyæmic
abscesses occur occasionally in the tissue of the heart, and may be
sufficiently superficial to burst into the pericardium, provided the
patient survive the constitutional disturbance long enough. Morgagni
observed numerous small abscesses form in the pericardium in
consequence of inflammation. Abscesses in the lung and pleura may
rupture and discharge their contents into the pericardial sac, and the
communication may heal. Thus, Balfour[32] records a case of a boy aged
thirteen who had evidences of effusion into the pericardium.
Paracentesis of the pericardium was performed, and thirty ounces of pus
were drawn off. While there was no evidence of communication with an
abscess external to the pericardium, yet an abscess was found at the
base of the right lung which was partially adherent to the sac. A
communication which was closed up by the subsequent pericarditis was
believed to have existed. The quantity of pus does not often reach the
amount just mentioned. The fact is, a small quantity may be attended by
fatal consequence. There may be pus in the pericardium when death is
occasioned by diseases involving the general system, as in scurvy,
erysipelas, pyæmia.
[Footnote 32: _Diseases of the Heart_.]
The SYMPTOMS of pyopericardium are those of acute or chronic
pericarditis, with marked depression. The physical signs are the same.
Indeed, there is no certainty in the diagnosis. Where there is, the
operation of paracentesis is strongly indicated. Free incision of the
pericardium has been recently practised by Rosenstein and by Samuel
West[33] for purulent pericarditis.
[Footnote 33: _The Lancet_, Dec., 1883.]
Pneumopericardium.
Pneumopericardium, or accumulation of air in the pericardial sac, is a
very rare affection. Yet Laennec[34] has stated that in his opinion air
as well as fluid accumulates in the pericardium in all diseases just
prior to death. Pneumopericardium may be associated with fluid, and may
or may not be attended with inflammation of the pericardium. As the
pericardium is a closed sac, air does not readily gain entrance. But it
may do so through perforations of the walls by stabs or gunshot wounds,
or by openings communicating with the oesophagus, lung, or stomach. Air
is then drawn into {791} the sac during the contractions of the heart.
Cases are on record of perforation of the sac with a knife,[35] and
through the oesophagus by means of a sword swallowed by a juggler.[36]
Sometimes the perforations communicate with organs that contain gas, as
the stomach or intestine or the oesophagus. Graves has recorded a case
in connection with abscess of the liver. When the pericardial sac is
intact, the distending gas may arise from decomposing fluid in the
pericardium: it is supposed that it may even be secreted by the blood
of the coronary vessels. Pure air, such as we breathe, is never
developed in the sac.
[Footnote 34: _Traité de l'Auscultation mediate_, chap. xxiii.]
[Footnote 35: Flint, _Diseases of the Heart_.]
[Footnote 36: Walshe, _Diseases of the Heart_.]
The accumulation of air in the pericardium which is sometimes noticed
after death has been declared by many to be the result of the
death-struggle. But it most likely occurs shortly before life ceases.
In such cases the source of the air or gas must be the blood, for it is
well known that blood contains several gases which may leave the
corpuscles and fluid in which they are held mechanically.
The DIAGNOSIS of the condition under consideration is difficult, since
we must chiefly depend upon the signs elicited by percussion. The
general indications are a feeling of oppression in the præcordia, a
sense of suffocation, fluttering of the heart; these, however, would
only point to some functional disturbance. Percussion shows a
preternatural resonance over the heart, the area of cardiac dulness
being restricted and indistinct in proportion to the amount of air or
gas contained in the sac. Emphysema of the margins of the lungs which
overlap the front of the heart may give the same resonant sound, but it
is not likely that emphysema of the lungs would be confined to their
margins only.
Uncomplicated pneumopericardium is not frequently met with, for the
affection is usually associated with fluid accumulations, and with the
percussion resonance there will be other phenomena presently to be
noted. On auscultation the heart sounds have a ringing character.
Pneumo-hydropericardium.
This, too, is a disorder of great rarity, and may be considered one of
the curiosities of clinical experience. It is indeed an unsolved
problem whether pneumo-hydropericardium ever exists except as a result
of the ingress of air from without the body or from an adjacent organ
through an opening made into the pericardium. Nearly all the cases that
have been reported have upon careful investigation exhibited the
evidence of perforation either by mechanical means or by ulcerative
action.
The SYMPTOMS of the accumulation of gas or air in the pericardium
associated with fluid are largely, if not entirely, the same as in
pericarditis with effusion. There is the same sense of oppression in
the chest, irregular rapid action of the heart, pain in the præcordial
region, difficulty of breathing, and there may be febrile excitement.
These symptoms are thus not of much diagnostic value unless accompanied
by the physical signs indicative of the disease. They are præcordial
bulging, diminished cardiac impulse, and the sounds elicited by
percussion and auscultation which show the presence of air and fluid.
On percussion we have clear or tympanitic resonance in the cardiac
region, somewhat modified, especially at the lower parts, by the
dulness from the fluid, and very changeable with the altering postures
of the patient. On auscultation the signs are variable. Laennec placed
great reliance on fluctuation audible with the action of the heart and
on deep inspiration, the heart sounds being heard at a distance. We may
also find what has been called a splashing or a {792} churning splash,
or the sounds of the heart may be extremely ringing, and even metallic;
there may be a combination of sounds, as in the case recorded by
Stokes,[37] where "they were not the rasping sounds of indurated lymph
or the leather creak of Collin, nor those proceeding from pericarditis
with valvular murmurs, but a mixture of various attrition murmurs with
a large crepitating and gurgling sound, while to all these phenomena
was added a distinct metallic character." In the case recorded by John
F. Meigs[38] loud splashing or churning sounds were audible three or
four feet distant from the heart; while Reynier[39] directs particular
attention to an intermittent sound, at first metallic, and resembling a
water-wheel.
[Footnote 37: _Diseases of the Heart and Aorta_.]
[Footnote 38: _Amer. Journ. Med. Sci._, Jan., 1875.]
[Footnote 39: _Arch. génér. de Méd._, Mai, 1880.]
In point of DIAGNOSIS we must be very careful not to confound the
resonance transmitted from a distended stomach to the cardiac region
with pneumo-hydropericardium. The rapid action of the heart and
shortness of breath due to the gastric distension may further mislead,
and the heart sounds may become sharply defined--the second more
ringing. I have several times been called upon for an opinion in cases
of the kind which were supposed to be pneumo-hydropericardium. Cavities
situated near the heart may also present transmitted cardiac sounds of
metallic timbre.[40]
[Footnote 40: Bauer, _Diseases of the Pericardium_.]
The PROGNOSIS is always very grave, yet cases of recovery have been
reported in instances of traumatic origin.
The TREATMENT is that of pericarditis, with great attention to
sustaining the action of the heart. This is chiefly effected by
stimulants. Opium for its quieting effect is also indicated. In cases
of marked cardiac pressure paracentesis has been recommended.
Cancer of the Pericardium.
Cancer of the pericardium is one of the rarest of all cancerous
affections, never occurring as a primary disease, but consequent on
cancer in some other part of the body, generally on cancer adjacent to
the heart. It may be the result of direct extension of cancer or of
secondary formations. In cancer of the pericardium the parietal layer
of the sac is the one always attacked. The extension of the disease
from the bronchi and mediastinal glands, from the lungs, pleura,
oesophagus, and stomach, is the common cause. Cancer will under certain
conditions produce lymphous exudation and adhesions and serous,
hemorrhagic, and even purulent effusions. When lymph is thrown out
friction sound exists and adhesions may follow. Serous effusion with
little or no inflammation is generally present in cancer of the
pericardium, and results from the obstruction in the vessels caused by
pressure or by direct extension of the disease to the vessels. If the
effusion be hemorrhagic, it can be attributed to the same cause. Pus is
generally the result of erosion of vessels and membrane.
The DIAGNOSIS of cancer of the pericardium is practically impossible,
for the physical signs are essentially the same as in pericarditis from
other causes, the darting, lancinating pain excepted; yet even the pain
may not be sufficiently typical to lead us to a correct conclusion.
Therefore, as a rule, the existence of the disease can only be
suspected, or regarded as very probable in consequence of the general
features of the malady.
The rarity of this affection is seen in the summary given in
_Ziemssen's Cyclopædia_. Köhler noted 6 cases of cancer of the
pericardium in 9118 autopsies; Günsburg found 1 case of cancer in 1700
autopsies; and Willigk, 7 cases in 477 autopsies of persons dying of
cancer.
Death, which is the result in all cases, is generally by exhaustion.
Other {793} diseases of a nature allied to cancer also attack or
involve the pericardium, such as lymphadenoma or lymphosarcoma in the
mediastinum; the pathology is practically the same as that of cancer,
and the general symptoms and the termination are alike.
Hydatids[41] give rise to growths which occasion a surmise of cancer;
so do those white calcified bodies formed in concentric layers known as
cardiliths. Neither has any diagnostic signs by which it can be
distinguished.
[Footnote 41: See Rokitansky's _Pathological Anatomy_, and Klob,
"Zeitschrift der K. K.," _Gesellschaft der Aertze zu Wien_, 1860.]
Tubercular Pericarditis.
Tubercular pericarditis is an exceedingly uncommon affection. Laennec
only met with 2 instances of it, Louis with but 1 case. It is never
primary, being always associated with tubercle in some other part of
the body. Among the earlier records we find the case of Baillie,[42]
who mentions "a case of two or three scrofulous tumors growing within
the cavity of the pericardium." The case had tubercles in the lungs,
and died with all the symptoms of phthisis, nothing indicating the
presence of tumors in the pericardium prior to death.
[Footnote 42: _Morbid Anatomy_, 5th ed., London, 1818, pp. 11, 17.]
Tubercle in the pericardium may remain latent or excite inflammation
which gives rise to the same physical signs and local phenomena as when
the pericarditis is of idiopathic origin. The tubercle is mostly found
beneath the serous layer of the pericardium, either cardiac or
parietal, and sometimes in the adhesions, and bears a close resemblance
to tubercular disease of the meninges, the peritoneum, and pleura. It
must be understood, however, that pericarditis may happen in a
tubercular person without being due to a deposit of tubercle in the
pericardium; and a deposit may occur in the adhesions in a case of
pericarditis in a tubercular person brought on by other causes than a
tubercular development in the pericardium, as the instances reported by
Burrows show.[43] Tubercular disease of the pericardium may be due, as
Weigert has proved, to infection by contiguity from the lymphatic
glands of the thorax. The pericardium may be free from tubercle, yet
the purulent fluid in it be filled with tubercle bacilli.[44]
Vaillard[45] declares the pericarditis to be dry in the majority of
cases. The disease generally happens under forty years of age, but in
Mickle's[46] case the patient died at the age of fifty-four.
[Footnote 43: _Med.-Chir. Trans._, vol. xxx. p. 77.]
[Footnote 44: Kast, _Virchow's Archiv_, June, 1884; see also _Medical
News_, Aug., 1884.]
[Footnote 45: _Journ. de Méd. de Bordeaux_, 1880, l. x.]
[Footnote 46: _London Lancet_, May 26, 1883.]
The differential DIAGNOSIS of tubercular pericarditis cannot be made,
as there is no positive physical sign distinguishing this form from any
other. If pericarditis either in its acute or advanced stage occur in a
tubercular person, and if there be neither rheumatism, Bright's
disease, nor pleuro-pneumonia, and if the person have not been
subjected to any injury in the præcordial region, the pericardial
affection may be presumed to be due to tubercle, but only an autopsy
would afford certain proof.
The PROGNOSIS is always unfavorable.
The TREATMENT is that of chronic pericarditis, sustaining the failing
nutrition as well as we can by cod-liver oil and other nutrients.
{794}
THE OPERATIVE TREATMENT OF PERICARDIAL EFFUSIONS.
BY JOHN B. ROBERTS, A.M., M.D.