HEART (DISEASES OF THE) 561 rheumatism, or rheumatic fever. The affec- tion is generally secondary to some other dis- ease, most frequently rheumatism. It some- times occurs in connection with either acute or chronic disease of the kidneys; also in some cases of pleurisy and pneumonia. It is a rare complication in cases of pyaemia, scurvy, erysip- elas, and the eruptive and continued fevers. As a primary affection it is exceedingly rare. An attack of pericarditis is generally indicated by acute, lancinating pain, referred to the re- gion of the heart, increased by a deep inspira- tion. Its intensity varies considerably in dif- ferent cases, being sometimes excruciating, and sometimes slight or even wanting. There is also more or less tenderness on pressure over the region of the heart, and its action is no- tably increased. With these local symptoms are associated those pertaining to the system at large which accompany symptomatic fever. As the affection is almost always developed in connection with other diseases, the symptoms ' the latter are of course combined with those the former. After a time, which in some consists of only a few hours, the local iptorns are liable to be modified by the ef- icts of the accumulation of liquid within the jricardial sac. The movements of the heart restrained in proportion as the liquid is mndant and rapidly effused. The pulse may >vv become feeble and irregular, and the pa- tient suffer from a distressing sense of oppres- ion, which is increased by any muscular ex- rtion or by emotional excitement. The com- ircssion of the heart may be the cause of jath, which sometimes occurs suddenly after some exertion or excitement. The diagnosis 1 recognition of pericarditis has been rendered >rompt and positive by means of auscultation id percussion. Soon after the attack, the idation of fibrine occasions a friction sound rith the heart's movements, and this is proof " the existence of the disease. Afterward, r hen considerable liquid has been effused into le sac, the friction sound may cease, but it is racticable to determine the presence and the quantity of liquid within the sac by physical igns, which are obtained by auscultation and jrcussion. The danger in cases of pericardi- depends, other things being equal, on the itensity of the inflammation, the quantity of raded fibrine, and the amount of effused juid. Aside from these conditions, much spends on the diseases with which it is asso- iated. When developed in connection with leumatism, it ends in recovery in the major- ity of cases ; but occurring in connection with J isease of the kidneys, with pleurisy or pneu- lonia, and in cases of pyaemia, it ends in death men oftener than in recovery. When death not sudden, the disease destroys life by slow thenia or exhaustion. As regards treat- lent, acute pericarditis claims in general the sures indicated in other inflammatory af- fections. These measures, however, are in lany cases to be modified by the circum- stances pertaining to the diseases with which this is associated. A very important fact proper to the affection, however, is that the source of danger is the weakness of the heart as a direct effect of the inflammation, and as caused by the pressure of liquid within the sac. This modifying fact contra-indicates ac- tive measures of treatment which in them- selves tend to impair the power of the heart's action. Whenever the effusion of liquid is such as to compress the heart, measures having for their object the absorption of the liquid are indicated. In the treatment of rheuma- tism an important object is to prevent the de- velopment of this complication; and clinical experience has shown that this object is pro- moted by the use of alkaline remedies. Chronic pericarditis may be a sequel of the acute affection, or the inflammation may be subacute from the first. In some cases the in- flammation continues with an abundant exu- dation of lymph, agglutinating the inner sur- faces of the sac, and proving fatal by slow ex- haustion. In other cases a large accumulation of liquid takes place, amounting to several pounds in weight ; and to the exhaustion inci- dent to the persistence of the inflammation is added the compression of the heart thus occa- sioned. In both varieties the disease, as a rule, proves fatal sooner or later. A few cases have been reported in which the liquid has been removed by puncture of the chest, and relief of distressing symptoms has been there- by obtained. The removal of liquid from the pericardial sac through a very small canula by means of suction, or, as it is called, aspiration, can be effected without danger from the opera- tion, and it remains to be ascertained whether in some instances recovery may not follow. Endocarditis. In this affection the inflamed membrane is in contact with the blood contained within the cavities of the heart; hence, al- though fibrinous exudation takes place as in pericarditis, the exuded lymph is in a great measure washed away from the membrane and carried into the circulation. A portion, how- ever, adheres to the membrane, roughening the surface in contact with the blood, and giving rise to an abnormal sound (an endocardial or bellows murmur), which is an important physi- cal sign of the disease. Moreover, upon the little masses of lymph which adhere to the membrane coagulated fibrine from, the blood contained in the cavities of the heart is apt to be deposited; and in this way are produced the so-called vegetations or warty growths which, being sometimes detached and carried into the arteries with the current of the blood, are arrested in vessels too small to allow of their further progress, become fixed, and occa- sion an obstruction which may lead to haemor- rhage (haemorrhagic infarctions), and to the impairment of nutrition within a circumscribed area beyond the point at which the obstruc- tion is seated. These movable plugs or em- boli, as they are termed, play an important part
