Pericarditis : Part 3

Disturbances of the Heart
by Oliver T. Osborne, M.D.

(Page 7 of 18)

If in spite of all the therapeutic measures suggested, the fluid increases and the pericardium becomes more distended and the heart's action more labored, paracentesis must be done. The point at which the aspirating needle should be inserted into the pericardium depends somewhat on the conditions in each individual case. It is often best to insert an exploratory needle first. This will determine the fluidity and character of the exudate. If pus is found, a more radical surgical procedure than simple paracentesis must be done immediately. The point of puncture for aspiration most frequently chosen is in the fourth or fifth intercostal space, about an inch to the left of the sternal margin. Paracentesis is also often done in the region of the normal apex beat. The position of the patient is determined by his dyspnea; he should lie in the position most comfortable for him. The fluid should be withdrawn slowly and the pulse carefully watched. The withdrawal of a small amount of fluid may later seem to be the starting cause of resorption of the rest of the fluid. On the other hand, it may often be not of more value than the simple removal of the immediate pressure, the fluid may again accumulate, and more radical surgery must be performed.

4. To Strengthen the Heart. - Most of the methods of meeting this indication have already been stated, namely, absolute rest; absolute quiet; the use of the bed pan; any movement that must be made should be deliberate; the nurse and other attendants must be quiet; necessary conversation must be brief, and every method must be used to quiet and prevent the heart's action from becoming rapid. The food taken should be small in amount and nonstimulating; that is, no tea or coffee should be given, and nothing too hot or too cold. Movements of the bowels should be caused with the least possible general disturbance. If the patient does not sleep, he must be made to sleep. The whole body and the nervous system must have periods of rest. If the heart is very weak, small closes of morphin may be used. If the heart is not weak, bromids or chloral may be given. If the blood pressure is high, such hypnotics will lower it, or if the heart is strong and the condition does not contraindicate it, aconite may be used in small doses, for a day or two, unless the fever is high and it seems advisable to use one of the coal-tar antipyretics, which reduce the blood tension and the heart activity.

As stated above, pain must not be allowed. Sometimes, when the heart has not been injured by prolonged fever, digitalis in small doses may slow the heart and act for good.

Convalescence. - The convalescence should be prolonged as in any other cardiac inflammation. The patient should be given more and more nourishing food, and the iron tonic may be changed to a capsule containing 0.05 gm. of quinin and 0.05 gm. of reduced iron, three times a day.

It is a question as to when patients convalescent from pericarditis should be permitted exercise. It has been thought that gentle movements and possibly exercise, sooner than theoretically justified, might cause the heart to beat a little more actively and possibly prevent the formation of tight adhesions between the two layers of the pericardium. Whether such activity of the heart will prevent adhesions is something that has not been determined.

The small doses of sodium iodid, perhaps 0.2 gm. (3 grains) two or three times a day, should be continued for some time. Iodid in this dosage does no harm and may do a great deal of good.

Adherent Pericarditis

Following dry pericarditis or pericarditis with an exudate, especially when the exudate is fibrinous in character, the fibrous substance which is not absorbed or resorbed may develop into connective tissue, and the two pericardial surfaces become permanently grown together, causing the so-called adherent pericarditis. These adhesions between the two surfaces of the pericardium may be general throughout the entire pericardial sac, or they may be limited to some one or more parts of the pericardium. Perhaps one of the most frequent points of adhesion is the anterior part of the pericardium, while the apex is the part most likely to be free, even when other parts of the pericardium have grown together. This freedom of the apex is probably due to the constant and more extensive motion of the apical portion of the heart, and is the reason that it has been suggested, as referred to under acute pericarditis, that, other conditions not contraindicating, the patient may be allowed to move about a little during convalescence to cause the heart to beat more actively. Sometimes the surfaces of the pericardium are not closely adherent to each other, but bands of adhesion stretch from one surface to the other.

After adhesions have taken place between the two layers of the pericardium, the action of the heart is impaired, serious interference with the cardiac action may develop, and sudden death may occur. If the heart is given all the rest possible during the acute phase of the disease, there will be less likelihood of the surfaces becoming so irritated that adhesions readily form. Anything which permits complete absorption and resorption of tile exudate will tend to prevent these hampering adhesions. If the adhesions are such as to cause irregular heart, recurrent pain and the danger of sudden death, surgical help has been suggested. This surgical procedure is to remove a portion of the ribs, perhaps of the third, fourth and fifth, to allow the heart more freedom of action to compensate for the impairment of its activity from the adhesions. Such an operation was first suggested by Brauer of Heidelberg in 1902.

The question of the best method of producing anesthesia in this condition of the heart is a serious one. A patient might die during the anesthesia; but he might also die at any time from cardiac spasm. In certain instances, in adults, local anesthesia might be sufficient. Pain reflexes, however, would be serious. Such an operation would be indicated when the apex is fixed so that there is a constant sensation of hugging of the heart at the fourth and fifth ribs, with paroxysms of pain and cardiac weakness.