On Pericarditis Scorbutica, and its Treatment by Paracentesis

ART. 28.—On Pericarditis Scorbutica, and its Treatment by Paracentesis. By Dr. KYBER. Half-Yearly Abstract of the Medical Sciences; Edited by W.H. Ranking, M.D. No VII, January-June, 1848, p.64-65. (Oest. Med. Wochenschr., and Monthly Journal.) https://books.google.fi/books?id=nPJYAAAAMAAJ Location of this file: https://doi.org/10.5281/zenodo.11175405 The summary of Kyber’s study was identified in the search for older reports on cardiac pathology caused by scurvy. A systematic review of case reports showed that vitamin C deficiency can cause right heart failure [1], and meta-analyses indicate that vitamin C can increase low levels of LVEF [2], decrease the risk of AF in high-risk populations [3], and decrease troponin levels in cardiac stress [4]. 1. Hemilä H, de Man AME. Vitamin C deficiency can lead to pulmonary hypertension: a systematic review of case reports. BMC Pulm Med. 2024 Mar 19;24(1):140. https://doi.org/10.1186/s12890-024-02941-x 2. Hemilä H, Chalker E, de Man AME. Vitamin C may improve left ventricular ejection fraction: a meta-analysis. Front Cardiovasc Med. 2022;9:789729. https://doi.org/10.3389/fcvm.2022.789729 3. Hemilä H, Suonsyrjä T. Vitamin C for preventing atrial fibrillation in high risk patients: a systematic review and meta-analysis. BMC Cardiovasc. Disord. 2017;17:49. https://doi.org/10.1186/s12872-017-0478-5 4. Rozemeijer S, Hemilä H, van Baaren M, de Man AME. Vitamin C may reduce troponin and CKMB levels after PCI and CABG: a meta-analysis. BMC Cardiovasc Disord. 2023;23:475. https://doi.org/10.1186/s12872-023-03459-6 This summary of Kyber’s study was cited in: Observations on Naval Hygiene and Scurvy; More Particularly as the Latter Appeared During a Polar Voyage. 1858, by Sir Alexander Armstrong, 1818-1899. https://archive.org/details/observationsonna00arms https://archive.org/details/b22334439 https://wellcomecollection.org/works/qfunupaq https://wellcomecollection.org/works/upp45by4 https://babel.hathitrust.org/cgi/pt?id=chi.28397279 https://books.google.fi/books?id=1W9aAAAAcAAJ “The third and last death which occurred on board the Investigator, previously to her abandonment, was the result of Pericarditis, attended with effusion, and was no less remarkable for the insidious nature of the disease than for the rapidity with which effusion took place. The disease as it occurred appears identical with that described by Dr. Kyber as Pericarditis Scorbutica…” Pericarditis Scorbutica, and its Treatment, by Paracentesis, by Dr. Kyber in Œst. Med. Wochenschr, and Monthly Journal, and Ranking's Abstract, Vol. 7, p. 65. 1 ART. 28.—On Pericarditis Scorbutica, and its Treatment by Paracentesis. By Dr. KYBER. Half-Yearly Abstract of the Medical Sciences; Edited by W.H. Ranking, M.D. No VII, January-June, 1848, p.64-65. (Oest. Med. Wochenschr., and Monthly Journal.) p.64-65 The disease here described is found on the extreme northern coasts of Europe, where scurvy reigns endemically from spring to autumn, and affects almost exclusively the class of sailors, who are, of course, peculiarly exposed to all the causes of the scorbutic diathesis1. This form of pericarditis appears to have been described by Cælius Aurelianus2 under the name of morbus cardiacus; but in more modern times has fallen into neglect, partly from the remoteness of the regions in which it prevails, and partly on account of the obscurity of the symptoms, and the deficiency of pathological observations. Dr. Kyber considers it as a very different disease, in its course and phenomena, from ordinary pericarditis. He thinks that its causes are the same as the scurvy, to which it is so closely allied; and remarks that the extent of its epidemic prevalence in a given year is always proportionate to the violence of scurvy in the same year. It seldom appears before February, attains its height about April, declines in summer, and disappears during autumn. It chiefly affects men from twenty-five to forty-two years of age; it has not been observed in women. A fourth of those affected are Russians, and three-fourths are Lettons (Lithuanians, &c.) and Esthonians, men mostly of a relaxed habit, and prone to hypochondriac and nostalgic affections. The external signs of scurvy are not always visible. In fatal cases the pericardium is found enormously distended, often measuring a foot in length, and containing three to eight, or even ten pounds, of dark red, or blackish opaque fluid, composed of serum and fibrin, with blood-corpuscles angular, and otherwise altered in form. The inner surface of the pericardium is covered with a coat of lymph, which is easily torn, reticulated on the free surface, of the colour of cinnamon. It can often be removed in layers, of which the palest and firmest are those attached directly to the membrane. The membrane itself is either injected, or stained with dark-coloured sugillations. On the part covering the heart, the lymph is often irregularly disposed in shreds, having a rugged or honeycomb appearance, and composed of bright red or yellow granules. The heart is diminished in size, and its substance is pale, flaccid, and easily torn. In cases where the fluid has been absorbed, adhesions are found between the layers of the pericardium. A similar exudation to that above described is frequently found in the pleura or peritoneum. The left lung is frequently much compressed by the distended pericardium, the right gorged with blood, or even inflamed. 1 A hereditary or constitutional tendency to suffer from a particular medical condition. 2https://en.wikipedia.org/wiki/Caelius_Aurelianus https://www.britannica.com/biography/Caelius-Aurelianus 2 The author describes the symptoms of this affection as occurring under two forms, acute and chronic; of which the former is commonly primary, the latter supervening secondarily on a catarrhal or rheumatic affection. The acute form begins with a sensation of coldness and prostration, oppression alternating with pain in the chest and epigastrium, rapid painless breathing, and decubitus on the left side; to these follows a discontented, gloomy condition, or complete apathy; with a pulse small, intermitting, or, when the effused fluid reaches two or three pounds, inappreciable. When the quantity of fluid is very large, the extremities are cold, the pupils dilated, the jugular veins distended, the expression exceedingly anxious; consciousness remains unaffected. The sound on percussion may be dull on the left front up to the clavicle; the heart’s sounds distinct or inaudible, if the fluid be large in amount; if this be small, there maybe friction-sound. The left side of the thorax is distended, and does not move freely; the lung on this side does not act; the right side, on the contrary, has puerile respiration3. The epigastrium is protruded, and sensitive on pressure. In the acute form these symptoms may be developed in twelve hours; in the chronic the progress is longer, the danger to life less immediate; but the retrograde process of the disease, in case of amendment, is also much slower, and less satisfactory in its results. In the treatment of this formidable affection, most of the remedies for ordinary pericarditis are either inapplicable from the cachectic constitution of the patients, or, if applied, fail to accomplish any good purpose. The apparent certainty of a fatal issue in such cases induced the author to afford a chance of prolonged existence by paracentesis of the pericardium. This operation, however, he has not yet attempted, except in cases where death seemed impending, and where the fatal issue could only be postponed by a bold measure of immediate relief. The operation performed by the author consists in the insertion of Schuh’s trocar between the fourth and fifth ribs of the left side, close to the sternum, and passing it a little obliquely outwards, till the point is felt to enter the pericardium. The trocar is then withdrawn, and the fluid allowed to flow through the canula, which is apt to become blocked up by lymph, and in this case must be kept clear by a stilet, or probe. By this method both the pleura and the internal mammary artery are avoided. The operation is painless, except where it is necessary to remove, by the adaptation of a syringe, either fluid or air which has entered into the cavity. The immediate effects of it are, return of the pulse, removal of the anxiety and dyspnœa, and renewed animal heat, with comfort and cheerfulness of mind; at the same time the friction-sounds return, and the heart’s sounds also become again appreciable. In the greater number of cases, life is merely protracted, as the fluid is again effused in a few weeks in as large a quantity as before, and becomes fatal. Nevertheless, in four cases the author has succeeded in accomplishing a radical cure. In three of these he administered, after the operation, the sulphate of quinine, which he recommends to be used in doses of six to fifteen 3Breathing with exaggerated respiratory murmur, as in the normal breathing of children. https://www.dictionary.net/puerile%20breathing 3 grains every two or three hours, with the object of affecting favourably the capillary system, and preventing the renewed effusion of serum. The dissection of patients who, after an attack of this disease, have died of some other affection, show that when a radical cure takes place, it is through adhesion of the pericardial surfaces, which occurrence the author believes, however, to be much rarer in this than in other forms of pericarditis. He thinks that stimulating injections might possibly conduce to this favourable result, especially as it has appeared to him that the entrance of a certain quantity of air is productive of no bad result, but even seems to stimulate the membrane to a healing action. In the four cases which were cured by paracentesis, the operation was only once performed. It was repeated (after the lapse of seventeen days) in one case only, and in this the result was unfavourable. He seems to think that if it were performed at an earlier period, it might be more frequently and permanently successful; but he has not thought himself justified in attempting this, having only operated in cases altogether desperate. The same disease has been described by Dr. Seidlitz, of St. Petersburgh, under the title of Hemorrhagic Pericarditis. Vide Forbes’s Brit. and For. Med. Rev., vol. i, p. 262. https://zenodo.org/doi/10.5281/zenodo.11175282 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5556493 https://archive.org/details/s2571id1380017/page/258/mode/2up Ranking’s Half-Yearly Abstract https://en.wikipedia.org/wiki/William_Harcourt_Ranking https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10038530 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10399383 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10435206 4