94 PRACTICE OF MEDICINE. 



Fifthly, in cases of anaemia, after hemorrhages, or when the blood 

 has become pale and watery through ill health, there will be a 

 loud systolic murmur, conveyed along all the arteries; and also 

 often accompanied by a continuous humming noise heard in the 

 veins, especially the internal jugular. This state is to be remedied 

 by nourishing food and tonics. 



Lastly, the sounds of respiration may imitate cardiac murmurs so 

 closely, that it may be necessary to make the patient hold his breath, 

 to distinguish their real source. 



INFLAMMATION OF THE HEART; ENDOCARDITIS, AND PERICARDITIS. 



These maladies are generally found to be concomitants of rheu- 

 ruatism. No doubt they do often occur from other causes ; and 

 they often occur, too in slight degrees without being complained of 

 or suspected. 



Symptoms. — The symptoms of endocarditis are, \s\.^ pahi in the 

 heart ; 2nd, disordered action of the heart which may be violent, or 

 else feeble, irregular, and intermitting ; 3rdly, some dyspnoea ; and, 

 lastly, ahnorinal sounds ; beginning with a roughness and after- 

 wards, a murmur, arising from thickening of, or deposit on some of 

 the valves. One or more of these symptoms, occurring in the 

 course of acute rheumatism, may be considered a sign of endocarditis. 

 The pain is sometimes so slight that the patient scarcely notices 

 it, if at all; but in dangerous cases is an extreme anguish, liable to 

 be followed by orthopnoea, restlessness, delirium and death. The 

 murmur sometimes is heard at the very beginning, whilst there is no 

 other symptom or complaint about the heart ; sometimes it does not 

 come on till the middle or end of the disease. 



The symptoms o? pericarditis are, 1st, pain in the region of the 

 heart, augmented by pressure and by a deep inspiration ; 2ndly, 

 irregular or violent action of the heart ; 3rdly, difficulty of breathing; 

 and, lastly, the physical signs — an exocardial murmur, caused by 

 i\jf^ rubbing of the roughened and inflamed serous surfaces of the 

 heart and pericardium against each other ; dulness of percussion 

 over an unusually large space of the preecordial region ; and some- 

 times a distinct undulation visible between the cartilages of the 2nd, 

 3rd, and 4th left ribs. The exocardial murmur resembles the rub- 

 bing of two rough surfaces against each other — it is called by Dr. 

 Watson the to and fro sound; which name well expresses its charac- 

 ter. The dulness on percussion, and the undulation, arise from the 

 presence of fluid efflision in the pericardium. 



The friction sound ceases of course if the heart and pericardium 

 become adherent together. 



Inflammation of the heart is sometimes attended with so much 

 nervous and cerebral irritation, as to mislead the practitioner, unless 



