In rheumatic inflammation of the pericardium there is in ordinary cases neither pain nor tenderness ; we notice no special hurry of breathing or of pulse ; the heart's action may be irreenlar, but there are no palpitations ; there is little change of colour in the ; and, unless the joint affection be severe, the temperature may be only moderately raised, or may even be normal. In spite, however, of the absence of symptoms, the child looks ill ; and while up and about—as he usually is before coming under the no tice of the medical attendant, if the articular inflammation is not severe— his countenance wears an expression of distress which quickly attracts the attention of his friends.
A little girl, aged three years and a half, was admitted into the East London Children's Hospital. She had had a slight cough for a fortnight, and was said to have looked ill. On examination, there was found dul ness of pyramidal shape in the praecordial region reaching upwards to the left sterno-chonciral clavicular, and to the right as far as one finger's breadth beyond the right edge of the sternum. The apex-beat of the heart was behind the fifth rib, slightly to the inner side of the nipple line. A faint impulse was felt all over the pixucordium. The heart-sounds were muffled, and a soft double friction-sound was heard at the base. The child complained of no pain. There was no affection of the joints. The other organs were healthy and the temperature was normal. A week after wards it was noted : " The cardiac dulness is as at last report, and there is the same friction to be heard over the preacordial region. Since admis sion the child has had no symptoms, and the temperature has been gen erally subnormal. Still the patient looks ill, and there is a distressed ex pression on the face even during sleep. Is now (3 P. )r.) lying asleep on her back, inclining to the left side. Pulse 88, regular ; respiration 28, nares riot acting. Some slight lividity about the mouth and under the eyes. Gen eral pallor of face, with a faint tinge of pink on her cheeks. -Lips rather pale. The superficial veins are visible over the sides of the neck and the backs of the hands, although not greatly enlarged." After a few weeks the physical signs of the heart became normal, and the child's health was per fectly restored.
The above illustrates very well the general appearance of a child who is the subject of pericarditis. In the large majority of cases, although he may
look ill and be lanemid, yet if there be no joint affection, he makes no spe cial complaint. An examination of the chest at once reveals the cause of the indisposition.
Still, it is right to say that in exceptional cases much more serious symp toms may be noticed. There may be tumultuous. action of the heart, with great dyspncea or even orthopncea, and lividity of the face. The counte nance may express the utmost anxiety, and the restlessness may be extreme. There is usually, also, -some puffiness of the face, and slight but general cedema. The gravity of these cases is probably owing to the participation of the heart substance in the inflammation. Again, in still other cases we find symptoms all pointing to the brain. There is high fever, with head ache and delirium (see page 159). Such cases are, however, chiefly inter esting from their rarity. They occur very seldom even in hospital prac tice, and are clinical curiosities which for practical purposes may be put on one side.
The beginning of pericardial inflammation is indicated by a more or less loud rub of friction accompanying the sounds of the heart. The rub' is best heard at the base, and is double, the systole and diastole being ac companied by a distinct catch or scrape, which is very superficial, and con veys the impression of being generated at a point nearer to the ear than the sounds of the heart themselves. Even if there be at the same time an en docardial murmur, the friction sound can be in most cases readily sepa rated by the practised ear, through its higher pitch and more superficial character, from the lower pitched and more deeply sounding murmur gene rated by the inflamed valve. A pericardial friction-sound is not, however, always high pitched, and even its superficial character may not be so de cidedly marked as would be expected. In certain cases a loud blowing sound is heard, which is indistinguishable by the ear alone from a similar sound of endocardial origin. Its mechanism must be then decided by other At first there is no alteration in the preecordial dulness, but in a clay or two, as fluid is poured out from the inflamed serous membrane, the limits of the heart's dulness are extended. At the same time the position of the apex-beat of the heart is raised, and the cardiac impulse is feebler than before.