PERICARDITIS. 405 



pulmonary pleura by the beating of the heart. This exfcra-pericardial 

 friction can only be distinguished from the intra-pericardial sounds 

 when it ceases entirely during inspiration. I have seen one very well- 

 marked case, in which it could be demonstrated, by means of ausculta- 

 tion and percussion, that the expanded lung entered the mediastino- 

 oostal sinus during inspiration, and separated the roughened surfaces 

 of the pericardium and costal pleura. 



It is not always easy to determine the character of the exudation 

 in the cases in question, although the cause of the disease and its 

 duration may enable us to form an opinion. The pericarditis which 

 complicates rheumatism is, if recent, almost always accompanied by a 

 sero-fibrinous effusion. That of septicaemia is nearly always purulent ; 

 the chronic variety often has a haemorrhagic exudation. It would be 

 unsafe to infer the nature of the effusion from the character of the con- 

 stitutional disorder, as the latter depends more upon the primitive dis- 

 ease than upon the form of exudation. Even physical research only 

 informs us, by means of friction-sounds, of the presence of rugged layers 

 of fibrin. When the exudation is purulent, the surfaces are not rough 

 enough to give rise to friction sounds. 



PROGNOSIS. As we have already said, pericarditis, supervening 

 upon .rheumatism, very rarely causes death, and this is also the case with 

 primary idiopathic and traumatic forms of the disease. Out of twenty 

 cases, seventeen of which were rheumatic, Bamberger did not find one 

 fatal case. The prognosis is favorable also where the malady proceeds 

 from pneumonia or pleuritis, as is shown by JZamberger's statistics. 

 It is quite otherwise where it complicates incurable disease, as it then 

 nearly always hastens, if it does not actually bring about, a fatal ter- 

 mination. 



In discussing the terminations of pericarditis, we have seen how 

 great the number of sequelae is, by which it is liable to be succeeded. 

 According to their nature, these exert more or less influence upon after- 

 life. 



TREATMENT. Upon the subject of treatment of pericarditis, we 

 may refer in great part to what we have already said regarding pleu- 

 ritis and endocarditis. 



General blood-letting is never required in pericarditis as such. Its 

 employment is to be confined to the very few cases in which the re- 

 pressed outflow from the veins into the heart causes symptoms of pres 

 sure upon the brain, and demands a reduction of volume in the circula- 

 tion. Local blood-letting moderates the pain somewhat, and is indi- 

 cated where it is troublesome. It is best to apply from ten to twenty 

 leeches, according to circumstances, to the left edge of the sternum. 

 The effect is astonishing in most cases. The use of cold deserves 



