SECTION SECOND.

DISEASES AFFECTING THE CIRCULATORY SYSTEM.

CHAPTER I.

Introductory Remarks-Pericarditis-Anatomical Characters-Clinical History-Pathological Character-Causation-Diagnosis-Prognosis-Treatment-Chronic Pericarditis—

Pneumo-Pericarditis.

DISEASES affecting the circulatory system are seated in the blood, the bloodvessels, and the central organ of the circulation-the heart. The morbid conditions of the blood, so far as they are at present known, are, in general, either common to different individual diseases, or they are involved in affections which are distributed in other nosological divisions. The consideration of these conditions, therefore, belongs to general, rather than special, pathology, and they have been considered in the first part of this work. Diseases of the vessels-the arteries and veins are fully considered by surgical writers, entering, as they do, much more largely into maladies which belong to the surgeon, than into those which fall within the province of the physician. Of the affections of the arteries, aneurisms situated within the chest and abdomen will alone claim attention in this treatise. Thoracic aneurisms will be noticed in this section; those situated within the abdomen will be referred to in connection with abdominal tumors, in the next section. Inflammation of the veins (phlebitis) has already been noticed in connection with purulent infection of the blood. This section will be devoted chiefly to diseases affecting the heart.

The

The clinical study of the diseases of the heart has been prosecuted with much success within the past few years, and, perhaps, in no other department of medicine is the recent advancement of practical knowledge more conspicuous than here. This is, in a great measure, due to the successful employment of physical exploration in the diagnosis of these diseases. discrimination of these diseases by means of the signs derived from the application of percussion and auscultation, has been brought to great perfection by the researches of Bouillaud, Hope, Stokes, and others. It does not come within the scope of this work to treat fully of the signs involved in the diagnosis of cardiac affections. For this important information the student and practitioner are referred to treatises devoted specially either to diseases of the heart, or to the physical exploration of the chest. I shall content myself here, as in treating of pulmonary affections, with a brief account of the phenomena determined by percussion and auscultation.

The diseases of the heart are conveniently arranged in the following groups: 1. Inflammatory affections. 2. Structural lesions. 3. Functional disorder. I shall consider them in this order, and the present chapter will be devoted

to one of the inflammatory affections. Inflammation affecting the heart gives rise to different affections according to the structure in which it is seated. Inflammation of the serous membrane investing the heart, or the pericardium, is one affection, called pericarditis. Inflammation of the membrane lining the cavities of the heart, or the endocardium, is another affection, called endocarditis. Inflammation of the substance of the heart, or the muscular walls, is distinguished as myocarditis. These three inflammatory affections will claim separate consideration.

ACUTE PERICARDITIS.

Pericarditis occurs as an acute and a chronic affection. Acute pericarditis will be now considered, and, afterward, the chronic form of the disease.

ANATOMICAL CHARACTERS.-The morbid appearances resulting from acute inflammation in this situation, are essentially the same as in other serous membranes when inflamed, for example, the pleura. Exudation of fibrin or lymph takes place in more or less abundance, commencing shortly after the development of the inflammation. The lymph is disposed in the form of a layer, or a series of layers, on the visceral and parietal surfaces of the membrane. It is at first soft and easily removed, but becomes dense and closely adherent in proportion as it is of old date. The movements of the pericardial surfaces frequently cause the lymph to assume a reticulated or areolated appearance, or it is disposed in masses, and it is sometimes in the form of numerous filaments or villous projections giving to the surface a shaggy, aspect. The vessels beneath the membrane may be congested, giving rise to arborescent redness, and spots of ecchymosis are sometimes observed. Different cases differ greatly as respects the quantity of lymph, and the extent of surface covered by it, as well as the appearances caused by the different modes in which it is disposed. The presence of lymph, here, as in other serous inflammations, is essential as proof of the existence of pericarditis.

More or less liquid effusion usually takes place, as in other serous inflammations. The effused liquid is serum, turbid from the admixture of lymph, and it contains, usually, flakes or shreds of lymph in greater or less abundance. The presence of a purely serous liquid within the pericardial sac, that is, without lymph, is not evidence of inflammation; it is a dropsical, not an inflammatory, effusion. The quantity of effusion in different cases of pericarditis varies greatly, amounting, in some cases, to a few ounces only and in other cases to a pint or more. The liquid is sometimes, but very rarely, purulent. It is sometimes sanguinolent.

If the disease progress favorably, the effused liquid is reabsorbed, and the pericardial surfaces, then coming into contact, are agglutinated by means of the intervening lymph. If recovery take place, the lymph is slowly absorbed, adventitious tissue becomes developed, leading to permanent adhesion of the pericardial surfaces. The adhesion by means of the newly formed tissue, may be limited to portions of the heart, and then the surfaces may become connected by bridles or bands which are sometimes drawn out to a considerable length; or, the adhesion may extend over a quarter, a half, or three-fourths of the organ; or, the surfaces may be everywhere united, the sac being completely obliterated. The latter is the most frequent result of acute pericarditis.

The most convenient mode of dividing the disease into stages, is the same as that adopted in pleuritis. The first stage extends to the time when effusion takes place to an extent sufficient to be appreciated by the physical signs. The second stage, or the stage of effusion, continues until the liquid

is absorbed. The third stage extends from the absorption of the liquid to the recovery, and this is, generally, the stage of convalescence.

CLINICAL HISTORY.-The symptoms present in cases of acute pericarditis are almost invariably made up, to a greater or less extent, of those arising from coexisting affections, for, in the great majority of cases, the disease is associated with either articular rheumatism, Bright's disease of the kidneys, or pleuritis with or without pneumonitis. Under these circumstances, it is not always easy to determine to what extent certain symptomatic phenomena are due to the cardiac affection. As a rule, the development of the inflarmation is attended with more or less pain, which, in some cases, is acute and lancinating, like the pain in pleuritis, and increased by forced breathing, so that the disease has not infrequently been supposed to be inflammation of the pleura. The intensity of the pain varies much in different cases; it is by no means always a prominent symptom, and it is sometimes slight or wanting. A dry, irritable, suppressed cough is generally present. Tenderness over the præcordia is more or less marked, and pressure in the epigastrium upward in a direction toward the heart, sometimes occasions acute pain. The pain produced by a deep inspiration may cause the patient to shorten this act, and, hence, the number of respirations per minute is increased. The ala nasi may dilate in inspiration. Patients sometimes manifest suffering from an indefinite sense of distress, without acute, localized pain, and, in females, hysterical phenomena may be associated with the development of the disease. The action of the heart is increased, amountipg, sometimes, to palpitation. The pulse is more or less accelerated, quick, and vibratory. The usual concomitants of febrile movement, viz., anorexia, debility, etc., are present. These are symptoms belonging to the first stage. The duration of the first stage is usually short. An appreciable amount of effusion may take place in a few hours, and it is rarely delayed beyond one or two days. The acuteness of the local symptoms, viz., pain and soreness, then diminishes, and, if the amount of liquid effused be sufficient to fill or distend the pericardial sac, symptoms are added which proceed from the pressure of the liquid upon the heart. These symptoms are, a sense of oppression referable to the præcordia; a tendency to syncope on exertion, which leads the patient to refrain as much as possible from movements of the body; feebleness and irregularity of the pulse, with a notable increase on emotional excitement or any muscular effort; dyspnoea, sometimes amounting to orthopnoea, if the accumulation of liquid be large and rapid; feebleness of the voice, and dysphagia in some cases, produced either by pressure of the distended sac on the esophagus, or as a neuropathic concomitant. Vomiting is an occasional symptom. Some cases are characterized by remarkable disturbance of the nervous system. Mental aberration, consisting in obstinate taciturnity and indifference, alternating with paroxysms of maniacal excitement under the influence of delusions which excite terror, is occasionally observed. Coma and tetanic convulsions have been known to occur. These symptoms are apt to mask the cardiac disease, and lead the practitioner to suspect disease of the brain. Autopsical examinations show that, in these cases, inflammation or appreciable lesions of the nervous system do not exist, and, hence, the phenomena are to be referred to functional disturbance of the nervous system.

The severity of the disease, as denoted by the symptoms, corresponds to the intensity of the inflammation and the amount of effusion. If the inflammation be slight or moderate and the quantity of effused liquid small, the disease may run its course without any symptoms denoting gravity, and the symptoms may not even point to the existence of any affection within the

chest. In other cases it is one of the most distressing and formidable of diseases. The symptoms due to compression, of course, diminish as the liquid is absorbed. The absorption sometimes goes on very rapidly, and, in this respect, different cases present great variation. If, instead of being absorbed, the liquid continues to accumulate, and life be not rapidly destroyed, the pericardial sac may become greatly dilated, and the affection becomes chronic. The rapidity and completeness of recovery after absorption will depend on the amount of lymph which has exuded. This may be too abundant to be absorbed, and the disease may end fatally after continuing for a greater or less period in a chronic form. In cases which go on favorably toward recovery, the action of the heart is apt to be feeble and easily excited during the stage of convalescence.

PATHOLOGICAL CHARACTER.-Acute pericarditis does not differ essentially in character from other serous inflammations. The same series of processes which take place in the serous inflammation considered in the preceding sec tion (pleuritis) occur in this inflammation, viz., exudation and liquid effusion, agglutination followed by permanent adhesion of the free surfaces of the membrane, and, sometimes, the formation of pus. Purulent pericarditis, however, occurs in a smaller proportion of cases than purulent pleuritis, or empyema. As in cases of pleuritis and other serous inflammations, so in different cases of pericarditis, both the actual and relative amount of lymph and serum differ greatly. In some cases, the quantity of lymph exuded is small and the effusion of liquid is abundant; in other cases, the lymph is abundant with but little liquid, and, again, in other cases, both lymph and liquid are either abundant or small.

CAUSATION.-Acute pericarditis may be produced traumatically by perforating wounds of the chest, or contusions. In one of the cases which I have observed, it was produced by a wound inflicted by a one-tined fork. Walsh refers to a case in which the pericardial sac was perforated in the juggler's trick of swallowing a sword, and fatal pericarditis induced. In the museum of Bellevue Hospital is a remarkable specimen, in which a set of false teeth is contained within the pericardial sac. The teeth were swallowed during profound intoxication, and, lodging in the lower part of the œsophagus, produced ulceration through this tube and into the pericardium, giving rise to fatal pericarditis. Exclusive of its traumatic origin, the disease is almost always secondary, and is developed in the course of acute articular rheumatism oftener than in connection with any other affection. Occurring in the course of rheumatism, it is distinguished as rheumatic pericarditis. It would appear, from statistical reports, to occur in cases of acute rheumatism in a proportion of about one to six. Generally it is developed in the early part of rheumatism, after more or less of the joints have been affected, but, occasionally, the pericarditis precedes the articular affection. When it follows the affection of the joints, it is not due, as was formerly supposed, to a metastasis of the articular affection, but it proceeds from the same morbid condition which underlies the latter; in other words, both are effects of a common internal cause, supposed to be the presence of lactic acid in the blood. Rheumatic pericarditis is almost always, if not invariably, associated with endocarditis.

Next in frequency to its development in the course of rheumatism, it occurs in connection with either acute or chronic disease of the kidneys. It is not very infrequent in cases of Bright's disease, and is an occasional concomitant of the renal affection which follows scarlatina, and in other cases of socalled acute albuminuria. Under these circumstances, its causation is imputed to the accumulation of urea in the blood.