Causes of Pericarditis.—The most frequent causes are blows or excessive pressure on the præcordial region, inflammation propagated from the lungs or pleura, and, far above all, rheumatism. From this cause, children and young persons suffer much oftener than others. The remaining causes are those of inflammation in general, viz. cold, febrile excitement, &c. [The disease may affect the fœtus in utero. In children that have died in less than forty-eight hours after birth, adhesions have been found between the pericardium and heart so strong as to lead to the belief that the disease had existed for some time prior to birth.] Prognosis. This disease, supposed by Corvisart to be necessarily fatal, has, by subsequent experience, been proved curable, and completely curable; but as the possibility of effecting a complete cure is limited to a very brief period, and as, unless it be complete, the patient almost inevitably dies sooner or later from the consequences, the disease must be regarded as one of the most formidable incident to the human race. Some of these consequences we shall describe in the next section under the head of adhesion of the peri cardium. Treatment of acute Pericarditis.-The antiphlogistic treatment, in as energetic a form as circumstances will allow, should be employed with the utmost promptitude. The loss of a few hours at first may be irretrievable; and hence hesitation and indecision may seal the fate of the patient. If the attack be recent, and the patient's strength will admit, blood should in the first place be drawn freely and by a large incision from the arm, so as to bring him to the verge of syncope. From five-and-twenty to forty leeches, according to the strength, should then be applied to the præcordial region, so soon as the faintness from the venesection disappears, and reaction commences, which generally happens in the course of from ten minutes to an hour or two. Unless the pain be completely subdued by these measures, the leeching may be repeated two, three, or more times, according to the strength, at intervals of from eight to twelve hours; or, what is a better rule, so soon as the pulse and action of the heart denote a recommencement of reaction. It is not, however, in every case that so active a treatment is required: we have seen a single prompt and abundant application of leeches, or a cupping, at once subdue every formidable symptom. When the patient, either from age, a feeble constitution, or the advanced state of the malady, cannot bear extensive depletion, local bleeding is, according to our observation, decidedly preferable to general; but it should be practised effectually, by cupping to twenty ounces or more, or by the there is inflammatory constriction of the orifices, a murmur will attend both sounds. Should the heart be dilated, as is frequently the case, the sounds will be increased; and should hypertrophy be conjoined with the dilatation, the impulse will sustain a corresponding aug. mentation of force. application of from twenty-five to thirty or forty leeches. When, from depletion having already been carried to a great extent, or from the advanced stage of the disease, it is not safe to draw much more blood, yet it appears expedient from the persistence of pain, &c. to draw some, we have cupping, produced more effect than a larger by generally found that a smaller quantity drawn by leeching. The cause of this probably is, that by cupping it is drawn more expeditiously. [Of late years it has been strenuously advised to bleed largely and repeatedly; and M. Bouillaud (Nouvelles Recherches sur le Rheumatisme articulaire aigu en général, &c. &c., 2d edit. Paris, 1830,) asserts, that he has, by this plan, rarely failed to cut short the disease, when he has been called early. He generally bleeds three or four times from the arm, to the amount of sixteen ounces each time, within the first three or four days, and employs leeching and cupping very freely. It is certainly good treatment to endeavour "to strangle" the inflammation at the onset by bloodletting; but if it should not succeed, when aided by the agents mentioned below, no time should be lost in having recourse to mercurial and other revellents. The safest course—even should the pulse be irregular and feeble, and the signs of general debility considerable-is to bleed, if the disease has been of short duration; but, on the other hand, as the writer has remarked elsewhere, (Practice of Medicine, 2d edit. i. 466,) the cupped and buffy appearance of the blood must not induce the practitioner to push the lancet too freely; for this, especially where the disease has a rheumatic origin, will commonly continue in spite of the bloodletting; and, it is affirmed, will even augment under its use.] While the bleeding is in progress, other means should not be neglected. The intestinal canal, if at all confined, should immediately be evacuated by a purgative enema. Three drachms of senna leaves, and an ounce of sulphate of soda infused in a pint of boiling water and strained, answers the purpose. At the same time, five grains of calomel with five or ten of comp. extr. of colocynth, and two or three of extr. of hyoscyamus, should be given, and in two hours be followed by a senna draught. The strength of the remedies employed must in each case be apportioned to the vigour of the patient's constitution; but the object is the same in all-expeditiously to prostrate the action of the heart, and for a time to keep it prostrate by preventing the re-establishment of reaction. If this object can be accomplished for the first twenty, thirty, or forty hours, the disease frequently does not rally, but remains perfectly under the control of remedies. We feel satisfied that a degree of activity in the first instance, which to some may appear excessive, is an ultimate source of economy to the strength of the patient; for the disease is subdued at once, and the protracted continuance of depletory measures, the most exhausting to the constitution, is rendered unnecessary. In addition to the above measures, diluent cooling drinks, as four scruples of supertartrate, or two of nitrate of potass in a quart of water, and flavoured at pleasure, should be allowed in unlimited quantity, in order, by diluting the blood to render it less stimulant to the heart. Nausea ting doses of tartrate of antimony, as one-sixth to one-eighth of a grain, every two hours, may be employed with advantage. [Or it may be given in contra-stimulant doses from 12 to 24 grains in the day, in divided doses, where the necessary tolerance exists. Colchicum often proves useful, and it has often been thought especially so when the disease is of rheumatic origin.] The diet should consist wholly of the weakest slops, as barley-water, gruel, weak tea, arrow-root, &c. But the antiphlogistic treatment alone is not to be relied upon: rarely, if ever, does it, in a severe case, effect a complete cure. The practitioner sees all his resources gradually exhausted, while the disease proceeds with an even, uncontrolled tenor to its fatal termination. Sometimes, indeed, all the other symptoms disappear, but the action of the heart remains stronger than natural; at other times the heart even regains its healthy action, and the cure appears complete: yet in both these cases the palpitation, accompanied with symptoms of organic disease of the heart, recurs when the patient resumes his accustomed occupations. The reason of this is very intelligible. Unless the effused lymph, as well as the serum, be absorbed, it causes an adhesion of the pericardium, and thus establishes destructive disease. Now antiphlogistic measures can neither prevent the effusion of lymph, nor with any degree of certainty cause its absorption. Mercury can do this, as is visibly displayed in iritis; mercury, therefore, is the sheet-anchor of the practitioner. Dr. Latham is of opinion that its success is restricted to the condition of its producing salivation rapidly. From many observations we are satisfied of the general truth of this remark, and would therefore give the remedy on this principle; but we have seen cases in which cures, not falsified after many months, were effected, though salivation was not produced. The mineral, however, was freely administered, and probably produced its specific effect, though not in an apparent manner. From five to eight grains of calomel, or from ten to fifteen of blue pill, prevented from purging by a grain or a grain and a half of opium, three times a day, commencing after the first bleeding and a purgative, generally produce the effect with sufficient, expedition. Inunction may be superadded or partially substituted, if mercury, taken internally, disagree. A manifest abatement of the symptoms generally takes place immediately on the effect of the remedy becoming apparent in the mouth, especially if a free salivation is established within the first thirty or forty hours. It should be maintained for a week or ten days, or even longer, unless the symptoms completely yield before the expiration of this period. Should pain continue in the advanced stages of the malady, and after the period for applying leeches has passed, blisters may be resorted to, and repeated in quick succession, with great advantage. I have occasionally found a third or a fourth necessary before the pain has been completely removed. In the repetition of blisters, as well as of leeches, cupping, and venesection; and in the selection of one of these remedies in preference to another, much must necessarily be left to the judgment of the practitioner. It is only experience which can teach the exact adaptation of remedies to the circumstances. It must also be left to his discretion whether to give sedatives or not. When the restlessness and nervous irritability were great, we have seen much benefit derived from tinct. hyoscyami, mxv. ad xx. with the same quantity of tinct. digitalis, in a draught three or four times a day. Sedative remedies, however, should not be given until the first severity of the inflammation has subsided; nor should they ever be allowed, by producing their poisonous effects, to confuse the symptoms, already sutfciently complex, in the latter stages. During convalescence it is sufficient to say that a very spare unstimulating diet and extreme tranquillity must be imperatively enjoined, until the action of the heart has become perfectly and permanently natural. An individual who has recently been affected with pericarditis is peculiarly liable to a recurrence of it, especially if it has resulted from rheumatism, and if the reparation has been incomplete. In this case, should rheumatism return, it rarely fails to be accompanied with a renovation of the pericarditic symptoms. This cannot be a subject of surprise; for it is consistent with general analogy that a part recently injured by inflammation is more susceptible than a healthy tissue of inflammatory action; the reason of which probably is, that the vessels of newly organized adventitious structures are more tender and irritable than others. Secondary inflammation, however, has not the same energy and intensity as that of a healthy structure; it yields more promptly to curative measures, and is more completely within the powers of medicine. Hence a first attack of pericarditis is more dangerous than any subsequent one. It is comparatively rare for a patient to die from the direct effect of a recurrent attack; and, what is still more remarkable, he may sustain several without being left in a materially worse condition than after the first. Much discretion, however, is requisite on the part of the practitioner to bring such recurrent attacks to a favourable termination; and the danger of doing too much is, perhaps, greater than that of doing too little. He must, in particular, be cautious of bleeding too extensively, with the object of reducing the excessive energy of the heart's action; for this energy, he must recollect, is a consequence not of the inflammation only, but partly also of an organic affection of the organ left by the primary attack. Nor is there the same motive for a vigorous employment of mercury; for the heart being already irreparably disorganized, it would be chimerical to entertain the expectation of effecting a perfect cure. The object, therefore, should be simply to prevent deterioration by combating the inflammation as it presents itself. For the accomplishment of this object, a moderate use of bloodletting and mercury suffices; and leeching or cupping on the præcordial region is more efficacious and less exhausting than venesection. Blisters are, in these cases, peculiarly beneficial; and they may be repeated in quick succession as often as they are required and can be borne. When there still remains a little lingering pain, which scarcely authorises vigorous measures, but cannot prudently be left, the most | ginate in an extension of the inflammation from valuable and convenient remedy has appeared to us to be, a plaster composed of a scruple of tartrate of antimony, five scruples of the emplast. picis comp. and one scruple of wax to diminish the tenacity of the adhesion. the pericardium. The cases of this description that are on record, are too numerous to be quoted. Several have fallen under our own observation. In this point of view, then, general carditis is not very rare. As softening and induration are of sufficient In these cases, also, where the sufferings of the patient, though perhaps not severe, are very pro-importance to demand separate articles, we refer tracted, and accompanied with inuch loss of rest, the reader to them for all that remains to be said great advantage is derived from a pill of from on general carditis. three to six grains of extr. of hyoscyamus at bedtime, and moderate doses of tincture of digitalis during the day, the specific poisonous effect of the latter remedy being obviated by omitting it for a couple of days after every three or four. Treatment of Chronic Pericarditis. When pericarditis is essentially chronic, and the cavity appears to contain fluid, counter-irritant remedies are the most suitable. After what has already been said, it will be sufficient merely to mention blisters, either in succession or kept open with savine cerate, the tartrate of antimony and pitch plaster, and likewise issues and setons. The last remedy, however, generally creates so much irritation as to do more injury by deteriorating the general health, than good by its local effect. Mercury to a moderate extent may, if discreetly employed, be advantageous by promoting absorption; but in general the patient is too much reduced by constitutional irritation to admit of more than the mildest action of this remedy. The diet may in chronic cases be more nutritious, comprising light animal food and broths. II. CARDITIS.-Inflammation of the muscular substance of the heart may be, 1. universal, 2. partial. We have already stated, when treating of pericarditis, that this affection is greatly aggravated by the coexistence of carditis. As the treatment of the two is the same, it is unnecessary here to enlarge on it. 2. Partial carditis, characterized by the exist. ence of an abscess or ulceration in the walls of the heart, is not very uncommon. Bonetus, in his Sepulchretum, has described a considerable number of cases. Abscesses are more rare than ulcers. The latter occur both on the external and the internal surface of the heart, and are consequent sometimes on inflammation of the membranes of those surfaces, and sometimes on steatomatous deposition in the cellular tissue beneath the lining membrane. The external ulcer is uncommon, but Oläus Borrichus, Peyer, and Graetz have left perfect descriptions of it. The first says, "Cordis exterior caro, profundè exesa, in lacinias et villos carneos putrescentes abierat." The internal ulcer is more common. Bonetus, Morgagni and Senac present many cases. have met with two or three. An ulcer, whether external or internal, may perforate the heart. We The signs of abscesses and ulcers vary in dif ferent subjects, and are not distinguishable from those of other affections. "I know not," says Laennec, "if auscultation will afford any more sure signs, and I avow that I think not." (De l'Auscult. t. ii. p. 664.) Ulceration is the most frequent cause of rupture of the heart,-fortunately a very rare occur rence. The existence of gangrene of the heart has never been distinctly proved, and the following reasons lead to the belief that its occurrence is perhaps impossible: first, the muscular tissue is one of those least susceptible of it; and, secondly, inflammation of the heart sufficiently intense to occasion it, is fatal to the patient before gangrene can take place. The cases on record of reputed gangrene, appear to have been nothing more than softening, which incipient putrefaction had rendered more analogous to gangrene. 1. Of universal carditis, with effusion of pus generally throughout the muscular tissue, there is not to our knowledge more than a single instance on record, and that occurred to Dr. Latham. "The whole heart," says he, "was deeply tinged with dark-coloured blood, and its substance softened; and here and there upon the section of both ventricles, innumerable small points of pus oozed from among the muscular fibres. This was the result of a most rapid and acute inflammation, in which death took place after an illness of only two days." (Lond. Med. Gaz., vol. iii. p. 118.) Laennec, never having met with or heard of a case of this kind, and considering an effusion of pus the only unquestionable sign of carditis, says, "there does not perhaps exist a single incontestable and well-described example of general inflammation of the heart, either acute or chronic." (De l'Auscult. t. ii. p. 554.) Independent of the above instance, however, there are probably many Adhesion of the Pericardium. — Pericarothers, which, though not attended with effusion ditis, both acute and chronic, and especially that of pus, will come under the denomination of uni- originating in rheumatism, frequently terminates versal carditis; for few will concur with this dis- in adhesion of the pericardium. Lancisi, Vieustinguished writer in excluding from the proofs of sens, Meckel, Senac, and Corvisart, are of opinion carditis softening and induration, with increased that, with a complete and intimate adhesion, the or diminished colour of the organ. These are patient cannot live in a state of health. We results of inflammation in other muscles, and know not how it is that Laennec and Bertin have analogy points out that they have the same origin formed an opposite opinion. The former states in the heart. Further evidence is derived from that he had opened a great number of subjects so the fact that, in cases of pericarditis, the charac-affected, who had never complained of any deters in question sometimes occupy only a certain rangement in the circulation or respiration; depth of the exterior surface of the organ, whence whence he infers that adhesion often does not in the presumption is almost positive that they ori- any respect interfere with the exercise of those functions. Our experience is entirely opposed to this doctrine. The complaints of the patient are, perhaps, not a just criterion, for we have often found the working classes disclaim dyspnoea when labouring under enormous hypertrophy and dilatation, and when that symptom obviously existed in a great degree. Many others, also, especially children, are naturally inattentive to their own sensations, and close interrogation is the only mode of ascertaining that after the attack of pericarditis they became incapable of some exercises, habits, or efforts, which they previously accomplished with facility. We have never examined a case of complete adhesion of the pericardium without finding enlargement of the heart, generally hypertrophy with dilatation. We have observed that cases of adhesion terminating in enlargement often hurry to their fatal conclusion with more rapidity than almost any other organic affection of the heart; and we have, on the other hand, repeatedly seen patients die from the consequences of an adhesion, the history of which we could trace back, eight, ten, or more years; yet such individuals would not unfrequently represent their health to have been perfect during the greater part of that period, and would not admit, until closely interrogated, that they had been more or less "shortwinded." Hence we infer that, though adhesion may not for a time create much inconvenience, its effects are ultimately fatal. This refers, of course, to intimate, not to loose adhesion. It appears to us that a tranquil, abstemious life, by which in other forms of organic diseases of the heart existence may sometimes be prolonged to its natural period, cannot be equally availing here; for as the action of the organ itself is a constant struggle, repose is impossible. How adhesion occasions hypertrophy is easily understood; for the organ must increase its contractile energy, in order to contend against the obstacle which the adhesion, by shackling its movements, presents to the due discharge of its function, and, as explained in the article HYPERTROPHY, increased action leads to increase of nutrition. The cause of the coexistent dilatation is not less manifest; as the shackled organ transmits its contents with difficulty, in a state of greater congestion than natural, and, as is more fully explained in the article on dilatation, permanent distension is the most effective cause of this affection. When the muscular substance is softened, as frequently happens, dilatation takes place much more readily, in consequence of the deficient elasticity or tone of the heart's parietes. this attentively in several cases of adhesion, but have not been able to detect it in any degree which could constitute a sign. Laennec, who was equally unsuccessful, thinks that it could not take place unless the stomach, by adhering both to the diaphragm and the abdominal parietes, formed the medium of retraction. In five or six cases we have remarked one sign, which has not, to our knowledge, been hitherto noticed; namely, the heart, though enlarged, beats as high in the chest as natural, and sometimes occasions a prominence of the cartilages of the left præcordial ribs. We should, indeed, naturally expect that the adhesion would brace up the organ, and that, when enlarged and not able to descend, it must, being bounded behind by the spine, force the walls of the præcordial region forward. Another sign, and perhaps the most characteristic of all, is an abrupt, jogging, or tumbling motion of the heart, very perceptible in the præcordial region with the cylinder. It is more distinct when the heart is hypertrophous and dilated; and under these circumstances we have found the jogs correspond with the ventricular systole and diastole respectively, that of the diastole being sometimes nearly as strong as the other, and having the character of a receding motion. This jogging motion is distinguished from the undulatory movement of fluid in the pericardium, both by its nature, by the synchronism of the jogs with the sounds, and by the feeling that the heart at each systole comes in immediate contact with the thoracic walls. A third sign consists in a bellows-murmur with the first sound, which we have always found present when the heart is enlarged and acting vigorously. Nor is it, in every case, confined to the heart: we have often heard it in the aorta, and formerly experienced difficulty in discriminating it from the murmur of dilatation of this vessel. (Vide Treatise, by Dr. Hope, p. 63.) Although, when the heart is dilated, the murmur in question may be occasioned partly by the relative smallness of the orifices, and the greater angles at which the currents meet in them in consequence of the unusually rounded form of the ventricles, as elsewhere explained, it is also, we believe, occasioned in a great measure by the sudden velocity with which the fluid is propelled, as it would not otherwise exist in the aorta. J. HOPE. PERICARDIUM, DROPSY OF. See Hr DROPERICARDIUM. press an inflammatory state of the serous membrane which lines the interior of the abdominal cavity, and invests all the viscera contained therein. When adhesion of the pericardium has proPERITONITIS, from TEρITOVELOV, peritomæum. duced hypertrophy with dilatation, its history-This is the term now universally used to exidentifies itself with that of the latter maladies, of which it renders the symptoms more severe and the progress more rapid. To avoid repetition, therefore, we refer the reader to the article HyPERTROPHY, and shall, here, only describe the signs which are pathognomonic of adhesion. Pain, tumefaction, and tenderness of the abdomen on pressure, are the most prominent symptoms which characterize this affection during life; and increased vascularity, thickening, effusions of coagulable lymph, of serum, of pus, or blood, are the principal local effects produced by it. These elementary features, accompanied in general with more or less of pyrexia, will exist in different do grees and combinations, in every variety of age, sex, or constitution, modified, however, by circumstances derived partly from the nature of the cause, and partly from the condition of the patient at the time of the attack. Peritonitis may assume either the acute or chronic form. It may exist as a sporadic disease, or prevail as an epidemic. It may either present itself openly, with a numerous group of wellmarked symptoms, or creep on in a latent state, with scarcely one of its characteristic features. It may be limited in its extent to a small portion of membrane, or spread over a large surface. It may run its course uncombined with any other affection, or be complicated with various diseases. There is no period of life exempt from its attacks. It may affect the infant, the adult, and the puerperal female pursuing the same course, and exhibiting similar effects in all, it yet presents a vast variety of symptoms in individual cases, principally according to the organ whose peritoneal covering is the chief seat of the inflammation. Pure peritonitis is exclusively confined to the peritoneum, without involving the muscular or mucous tissues of the intestines, and can in most cases be distinguished by peculiar symptoms from inflammatory affections of those tissues. Not uncommonly, however, inflammation commencing in one tissue extends to those contiguous; but this is by no means uniformly the case; frequently the very opposite effect is induced in this disease, and the intestinal mucous membrane becomes remarkably pale, while the peritoneum is acutely inflamed. We shall proceed, in the first place, to notice the disease as it exists in the acute form in the different periods of life. tain extent, to similar injurious impressions from external agents, and their organs are at least equally susceptible of morbid actions. Symptoms. The abdomen of the child presents a tumefied and tense appearance, and is elevated in a point towards the umbilicus. This distension is caused in the early period of the disease by flatus in the intestines: it is accompanied by some dyspnoea, which does not, however, always indicate a pulmonic affection, but is produced by the obstruction which the diaphragm suffers in its descent from the distended abdomen, and the pain which its movements occasion by the friction of the inflamed peritoneal surfaces against each other. There is constant abdominal pain, which is much aggravated by pressure. The countenance exhibits an expression of suffering: the features are contracted, and the little patient cries almost without intermission. Vomiting usually is present, and the bowels are in most cases constipated. There is restlessness, with general debility; hot, dry skin, and frequent, weak pulse; and, if prolonged into the chronic state, the child becomes emaciated, and dies exhausted. It is difficult to distinguish this disease from infantile enteritis, with which it is occasionally com. plicated. In its simple form it is usually attended with more abdominal tenderness on pressure. Constipation generally exists in peritonitis, while diarrhoea is frequently an attendant on inflammation of the mucous membrane. The appearance of the tongue may assist in the diagnosis, being, in the latter affection, generally furred with red tip and edges, and red papilla, while in simple peritonitis this redness is not generally present. Peritonitis is a much less frequent disease during infancy, not being so likely to be induced by irregularities of diet and the other injurious agents to which children are particularly exposed, and which are common exciting causes of enteritis. M. Billard observes that it may be distinguished from pleuritis by the sonorousness of the chest, and from flatulent colic by the pains being remitted in the latter affection, and ceasing on the expulsion of gas. (Maladies des Enfans, Paris, 1828, p. 449.) The prognosis in this disease is generally unfavourable. The post-mortem sppearances do not differ from those which the disease presents in adults, and which will be hereafter described. I. ACUTE PERITONITIS IN THE INFANT.— This disease may attack the infant during its intra-uterine life. Its exciting causes during this period of existence are obscure: they may possibly be transmitted from the mother to the infant, or originate from an internal strangulation of the intestines, of which M. Legoues and M. Ducis have seen examples. However difficult it may be to assign a satisfactory cause for its origin, its existence has been unequivocally demonstrated by the post-mortem appearances which infants who have died a few hours after birth have exhibited. In some cases of this kind, the usual effects of peritoneal inflammations, adhesions between the Children of a scrofulous habit are subject to a intestines, false membranes, and sero-purulent form of chronic peritonitis, which deserves distinct effusions into the abdomen, have been detected-notice: it is characterized during life by great effects which must have been produced during the abode of the infant in utero. Five cases of infants who died a few hours after birth have been detailed by M. Billard, in which the above appearances were found. In one instance the child was emaciated and pale; and old, solid adhesions were discovered in the abdomen, apparently indicating that the disease had existed for some time previous to birth, and had probably become chronic before it terminated fatally. In the other four cases, the infants presented nothing unusual in their external appearance. The causes which may excite peritonitis during the period of lactation are not very evident. They probably are essentially the same as may operate during adult years. Infants are exposed, to a cer tenderness of the abdomen on pressure, with occasional paroxysms of acute pain, at first coming on only once or twice a day, but afterwards becoming more frequent, after which the child appears quite lively, and free from indisposition. At first the pain is limited, but afterwards extends over the whole abdomen, which in the early stages becomes swollen and tense, but afterwards subsides: the pulse is generally about 100, with some strength and fulness, the tongue clean, appetite irregular, but generally good, and frequently voracious; some thirst, the bowels free, the evacuations unusually large in quantity, and peculiar in appearance, consisting generally of a whitish-brown matter, of the consistence of a thin pudding. This state of the bowels may continue for six weeks or |