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.
MYOCARDIAL DISTURBANCES
While the myocardium is the most important muscle structure of the body, it has but recently been studied carefully or well understood clinically or pathologically. A heart was "hypertrophied" or "dilated" or perhaps "fatty." It suffered from "pain," "angina pectoris," from some "serious weakness" or from "coronary disease," and that ended the pathology and the clinical diagnosis. This is the age of heart defects; no one can understand a patient's condition now, whatever ails him, without studying his heart. No one can treat a patient properly now without considering the management of the circulation. No one should administer a drug now without considering what it will do to the patient's heart.
Although we are scientifically interested in the administration of specific treatments, antitoxins and vaccines; although we have a better understanding of food values, and order diets with more careful consideration of the exact needs of the individual, and although we are using various physical methods to promote elimination of toxins, poisons and products of metabolism, we have until lately forgotten the physical fact that one thirteenth of the weight of a normal adult is blood. A man who weighs 170 pounds has 13 pounds of blood. This proportion is not true in the obese, and is not true in children. Whether the person is sick in bed, miserable though up and about, or beginning to feel the first sensations of slight incapacity for his life work, his ability properly to circulate this one thirteenth of his weight through the various arterial and venous channels and capillary tracts must, with the increasing tension and speed of our lives, be taken into consideration.
The more and more frequently repeated statements that the operation was successfully performed but that the patient died of shock, and that the typhoid fever and the pneumonia were being successfully combated, but that the patient died of heart failure, together with the increase in arteriosclerosis, cardiac disturbances and renal disease, emphatically present the necessity of more carefully studying the circulation. A better understanding and the constant study of the blood pressure shows nothing but the necessity of the age. The unwillingness of the patient to suffer pain, even for a few minutes, without some narcotic, generally a cardiac debilitating drug, means that, if he is a sufferer from chronic or recurrent pain, he has taken a great deal of medicine which has done his heart no good. Repeated high tension of life raises the blood pressure and puts more work on the heart. Therefore the heart is found weary, if not actually degenerated, when any serious accident, medical or surgical, happens to the patient.
The requirements of the age have, then, necessitated that the heart be more carefully studied, and therefore the heart strength and its disturbances are better understood. The mere determination as to where the apex beat is located, and as to what murmurs may be present is not sufficient; we must attempt to determine the probable condition of the myocardium. The following conditions are recognized: (1) acute myocarditis, (2) chronic myocarditis (fibrosis, cardiosclerosis), (3) fatty degeneration, and (4) fatty heart.