OCR Text |
Show DISEASES (II? THE ORGANS (II? "INFLATION. DISEASES ()1? THE IIEAII'I‘ AND ITS MEMBRANES. ot' the serous membrane must not be confounded with Suc'rtox II.-T.\m.n I. Figures 1 and 2 represent two cases of Il:emorrhagic l'ericarditis. Fig. I has no clinical history. Fig. 2 presented only (lyspntea and delirium as symptoms. An enlargement of the heart was diagnosed during life, but no pericarditis. Autopsy-Fig. 'l. The heart is of a. normal size. The pericardium is very much distended. A great quantity of sero-sanguinous liquid flowed out as soon as the sac was opened. The surface of the heart was covered with a pseudo-memb 'ane of a deep brownish-red color; thick and wrinkled, very little coherent in its superficial layer, and very cohesive and g 'anular in its deep layer, and attached to the visceral layer. The heart was neither changed in texture nor color. The subserous cellular tissue was neither infiltrated nor injected. Fig. 2. The heart was very large; enlargement *aused by distention of all its ravities. It is here turned up to show its posterior surface. The pericar- dium is enormously dilated. The whole surface of the heart was covered with a very deep red pseudo-membrane, very thick, areolated, and covered all over with conical projections, of ditt'erent sizes and forms. which chiefly were situated on the left border of the h‘art. Altogether it had th 5 app xarance of a large pine cone. A great number of long filaments, some thick, some very slender. projected from the h tart. The peri 'ardium was also covered, but with a smooth pseudo-metabrane, on its inner surface. Some projections were situated here and there, and seemed to be continuations of those of the heart. The pseudtt-membrane was formed of two distinct layers: (I) a superficial, clotty. very dark brownish-rcd. little cohesive and somewhat elastic; and (:2) a deep. of white color. covered with tubercles or granules, very cohesive. easily separable from the superficial, but sutiicieutly adhering to the serous covering of the heart. ()1) separating the latter. short strings which united them were seen; also red spots upon the whole parted surface. These were the newly-Ii,)rmed vascular net- works. covering the entire surface of the pseudo-mem- brane. The presence of two 1usetulo-nletnbranous layers. of very difi'erent aspect. seems to indicate two distinct periods of the pericarditis. The granular layer. covered with vascular net-works. and very adherent to the walls of the heart. must be of prior date than the soft elastic layer, which seemed not yet organized. The clot granules tubercular formations. They are never converted into real tubercles. but become either eventually hardened or are gradually absorbed. 'I‘ubercular granulations. however, may readily be formed not only in old. but also in very recent. pseuthi-membranes of the peri 'ardium. .\s a general rule. they are associated with pulmonary tuberculosis and pleural exudations existing in chronic pneumonia. In such 021303. the tubercles form. very often, dense, agglutinated masses. highly vascular. and very elastic, and cover the heart and pericardium. The deep red color of the 1)seudo-membraue was. here, due to a quantity of bloody serum with which it was saturated. ,In cases where the pericardium is much distended by profuse exudation, the heart is pressed down deep in the pericardial cavity. and the exudation occupies its upper portion. It also presses the lungs back from the anterior thoracic wall. In this way the space of dull sound extends upward. and its limits may reach the third. second. and. in extreme cases. even the first intercostal space. The left sternal border. at first. cottstitutes its inner boundary. gradually it extends its limits downward and to the right, and but slightly to the left and outward. Thus. a very large triangular space of dull sound is formed in the anterior portion of the thorax. In voluminous exudations the heart-pulse is felt much below its ordinary position. It may then be felt either over several intercostal spaces. or may become perfectly imperceptible, especially if the patient occupies a supine position. TL‘ .v\ 1') I. Id [Ll/(ll'U-jlf'l't-(‘UI‘llfffn‘. (V‘.\si<:.--- lx'I'r. a shoemaker. thirty-four years old; entered hospital May 223. 18-. Face of a purplish color. and bloated. Lower limbs much infiltrated. N'l/IH/I/IIIHN. - Breathing. dyspntea and orthopmea: oppression so great that he can neither inspire nor expire completely. Thin, wriggling pulse: frequent. irregular. about 110. lleart-pulse very feeble and almost inaudible to the ear. Application of the stethoscope fails to carry the sound. l)ull sound over the region of the heart very extensive. nor is the heart-beat per- ceptible. Home efi'usion in the abdomen. The region of the liver somewhat sensitive to the touch. No signs of pleuritic etl'usion. Bronchial lv'ale. indicating 'indu- ration of the ape\ of right lung. \Vas treated with digitalis. The uc\t day. some relief of orthopntea. but l"rom the Sth of»l11ue. difiieulty of only short duration. is" iio\ ll., "Ihcn the patient stands up. the pulse will at once become perceptible. but the dull sound will then extend to the left. far beyond the locality of the pulse. The cardiac sounds. when auscultated. will be very feeble. and frequent. and seem as if they came from 21 distance. There are cases in which the exudation com- presses the basis of the left lung until it becomes solidified; under such conditions the hepatized portion of the lung will still further increase the area of the dull sound. and make it appear as if the exudation be more extensive than it really is. Auscultatiou over that region will then prevent an error of diagnosis. The most constant symptom of pericardial ctl'usiou is, an increase of the triangular space of dull sound in the cardiac region. .\s a rule. when the dullness on percussion extends much farther externally than the pulse, of the heart. and the radial artery pulse is at the same time stronger than that of the heart. exudation within the pericardium may be predicated. fl. 1.. of breathing increases. Oedenia of face. and some in the body. .\t very rare intervals he can lie on his right side. otherwise he maintains a sitting post are: the right side is. theretore. most infiltrated. (‘ontinued explora- tion of the thorax shows an increased dull-sounding space. but no infiltration in the pleural cavity. (‘ontin- ued bronchial respiration at the apex of the right lung. and a (‘Utll‘fit‘ mucous and sibilating Itale in other portions of that lung. (‘repitns sound in the middle portion of it. l'ulse still very irregular and feeble. June 17. llas ditliculty in swallowing. from (‘,\t‘('.\\l\(‘ shortness of breath. June 21!. Ila-moptysis. .\|most sutfocating: can only sit up with his head very high and leaned on the right to spit ltltltill. Abdotnetl \'t‘l'\ tt'lltlt‘l': Ul‘llltlltlltl‘ll; unable to excesshe perspiration: almost pulseless. llied nto\e; till the Sltlt‘. 'llllt‘ following davs. continues 2‘31l] of June in full possession of his senses. |