symptoms depend essentially upon the form of the pericarditis. In dry pericarditis the most important symptom is a friction murmur which can frequently be felt. The friction murmur may vary in character. Sometimes it is a low touching or rubbing sound, at others a stronger, grating sound, which is heard irregularly above the heart sounds and is continued longer than these. This mur mur is usually loudest at the base of the heart and changes in intensity in children with change in position or pressure with the stethoscope. It becomes louder when the child sits up, walks or bends over or when pressure is made with the stethoscope; and lower when the child lies on its back. It is more easily heard in children than in adults, but the differential diagnosis between endocardial and pericardial murmurs is sometimes very difficult, in children especially. This is true when valvular affections exist with pericardial affections, when both kinds of murmurs eome into question. If the pericarditis spreads, a second point of maximum intensity of the friction 111111.MUt is as a rule noticed, at the apex. Friction murmurs are sometimes heard also in forms of pericarditis with effusion, in certain positions of the body, varying with the cases, in which both layers of pericardium, covered with fibrinous exudate come near enough to touch with the beats of the heart. As pericardial layers are kept separated with larger effusions, the friction murmur usually disappears when tbe exudate grows larger, and in its place appears a decided enlargment of dulness, which increases gradu ally- as the apex-beat grows weaker.
Small effusions in children produce no change in the cardiac dulness and often no other symptoms of importance. Larger effusions give that triangular area of dulness, well known in the symptomatology of peri carditis in adults, of which the apex lies at the third or second rib accord ing to the amount of the effusion, while the left .side of the triangle— and this is especially characteristic—reaches far to the left of the point where the apex-beat is palpable.
Very frequently Wi tit large effusions, especially in small children, a general diffuse vibration or undulation of the entire anterior chest wall is palpable, with weakened or absent apex-beat, viinle a marked for ward bulging is never absent.
Large effusions produce visible dilatation of the left half of the chest which does not move to and fro with respiration. The heart sounds are weak, pendulum-like, embryocardial in type. The pulse-rate is considerably accelerated, sometimes reaching 150 to 180 to the minute in small children.
The apex-beat. in exudative pericarditis of children, may MONT to various places within the area of dulness, by change of the child's posi tion, if the heart has not lost its motility in the pericardium filled with effusion. When the child bends over or is placed in the knee-elbow position, the apex-beat, which may previously have been absent, may reappear, an important sign of exudative pericarditis.
Pericarditis of children escapes recognition very frequently when associated with left-sided pleural effusion. A massive pericardial effusion, too, considerably compressing the left lung, might be mis taken for a pleural effusion if sufficient stress were not laid upon the position of the apex-beat of the heart which is shoved to the right side with pleurisy, and is absent with pericarditis.
The general symptoms of acute pericarditis are not characteristic at, the beginning. Palpitation, rise in body temperature, sometimes arrhythmia and pain in the precordial region point to a cardiac affec tion. The friction murmur or triangular dulness first make the diagnosis certain. In the chronic forms, subjective symptoms are sometimes very slight and are totally concealed by the symptoms of the funda mental disease. Important is the rapid appearance of high-grade dyspncea in small children, even with slight effusion, with which cyanoids may for a long time be absent. Decided orthopmea with increase in the cardiac dulness and weak apex-beat must lead to the diagnosis of pericarditis in children, even without the prese.nce of the friction mur mur. Tuberculous pericarditis often runs its course entirely without symptoms.
Symptoms due to changes in the heart muscle are never lacking if the pericarditis lasts some time. Acute dry pericarditis may rapidly lead to insufficiency and dilatation of the cardiac musculature. espe cially in delicate children; the exudative form, by compression, may produce serious circulatory disturbances. The addition of pericarditis to heart lesions in children exerts an unfavorable influence upon the compensatory relations of the cardiac muscle. As the result of large pericardial effusions, compression of the left lower lobe of the lung occurs very frequently in children. Pins' pseucloplevritic symptom of peri carditis depends upon the disappearance of the symptoms of pleurisy (dulness, friction miffinur and diminished vocal fremittis) when the patient is placed in the knee-elbow position. According to Ouinon this change in physical signs does not occur at once when the position is changed, but only after some moments. According to Aviragnet and Olsnitz, Pins' symptom can be found in exudative pericarditis in child hood.
Prognosis and course of pericarditis is different whether it be dry or exudative in form, and the latter varies according to the kind of effusion. But pericarditis belongs to the most serious diseases of childhood, as complete recovery seldom occurs, and even in cases running a favorable course, adhesions between the layers of the pericardium may result, which will be decidedly deleterious to later life, and to further bodily development. The best prognosis can be given in pericarditis duc to acute rheumatism which if there be no cardiac lesion, may recover without any evil result. Pericarditis following pneumonia and the acute infectious diseases is less favorable, chiefly because the resistance of the heart has always been decreased previously by the toxins of the disease. Purulent and haimorrhagic pericardial effusions, with sepsis and tuberculosis, naturally give an absolutely fatal progno.sis. If death occurs, it always is dependent upon insuffi ciency of the heart muscle and cedema of the lungs.