A-little girl, aged seven years, had a mild attack of rheumatism fol lowed by chorea. Six months afterwards the choreic movements returned, and she was admitted into the East London Children's Hospital. At this time the heart's apex was noted to be beating between the fifth and sixth ribs, one-fourth of an inch outside the nipple line ; and a soft systolic murmur was heard at this spot. After being a few days in the hospital, the child's temperature rose from normal to 103.8°, and a double rub was detected over the prpecordial region. There was also a patch of pneumo nia at the base of the right lung. Some days afterwards effusion was found to have occurred in the pericardium, the limits of the heart's dulness were extended, and the heart's apex was raised to between the fourth and fifth ribs in the nipple line. The double friction was still heard—most distinctly at the level of the third left sterno-chondral articulation.
If much lymph and little fluid be thrown out, the hand placed upon the priecordial region can often detect a distinct fremitus with each beat of the heart. When a considerable quantity of fluid is effused into the pericardium, the resulting area of dulness takes the shape of the contain ing sac. It becomes triangular or "pyramidal" in form, with the apex di rected upwards towards the top of the sternum. A moderate effusion does not prevent the friction-sound from being heard, but the rub becomes less intense and less crisp than before, and the heart-sounds are muffled and distant. In great effusion the chest-wall in the cardiac region may be bulged, and on careful inspection the eye can often detect a distinct undulatory movement with each beat of the heart in the intercostal spaces.
An important distinguishing mark of pericardial friction is, besides its superficial character, the irregularity of distribution of the sound. Endo cardial murmurs are carried along with the blood-current. Pericardial frictions may be limited to a small area, or heard equally loudly over the whole prEecordial region ; in either case they do not follow the rules which regulate the transmission of heart-murmurs. Further, a pericardial rub is intensified by pressure, and is heard better during expiration than when the lungs are expanded. As the fluid and lymph become absorbed, the limits of dulness gradually return to their former dimensions ; and the friction after a time becomes fainter and fainter and gradually disappears. If the lymph has been exuded in large quantity, adhesion of the pericar dium may take place. Unless there be also adhesion between the pericar
dium and the adjacent pleura, there are no physical signs by which this condition can be detected. If the pleura and pericardium be adherent, the intercostal space corresponding to the apex of the heart is depressed at each impulse. Adherent pericardium is generally followed by hyper trophy of the heart.
The fluid in pericarditis sometimes becomes purulent. The suppu rative form of pericarditis is more common in cases where the inflammation has extended to the pericardium from the pleura ; although it may no doubt also occur without the pleura having been previously affected. In the cases of this form of pericardial inflammation which have come under my notice, the patients have complained of pains in the chest or epigas trium ; the temperature has been high at night (103° to 104°), with a par tial morning remission ; pericardial friction has disappeared early ; ab sorption of the effusion, if it had begun at all, has been slow and incom plete, and towards the end of the disease slight but general oedema has been noticed without any albumen being discovered in the urine. These cases almost always end fatally.
When endocarditis occurs, the valvular lesion is indicated at first by no external signs, and can only be discovered by physical examination. With the stethoscope we hear a low-pitched soft murmur at some point of the precordial surface, indicating, according to its site and rhythm, ob struction or incompetence of one or another of the cardiac valves. The af fection of the valve may be accompanied by increased frequency of the pulse and some palpitation ; but while the patient is at rest in bed these symptoms are very exceptional. Tenderness is never present, and it is rare for the child to complain of pain or uneasiness about the chest. The valve affected is most commonly the mitral, although the aortic semilunar valves are sometimes inflamed alone, or in conjunction with it. The le sions are almost invariably limited to the left side of the heart.
Endocarditis may occur without implication of the pericardium, or the two lesions may be combined. In the latter case the endocardial murmur may be completely masked by the external friction-sound, and may only be discovered as the latter subsides. If unaccompanied by inflammation of the pericardium, endocarditis, although a very serious misfortune as re gards the future of the patient, acids little, if anything, to the immediate danger.