ADHESION. OF THE HEART AND PERICARDIUM. 407 



two surfaces is incomplete, remnants of effusion now and then exist, as 

 we have already described. , , 



SYMPTOMS AND COURSE. As but a small portion of the pericar- 

 dium is attached to the thoracic wall, and even that is held by loose 

 cellular tissue, a simple adhesion of the two surfaces does not seem 

 materially to interfere with the movements of the heart. Functional 

 disturbances, observed to accompany this condition, usually depend 

 upon a concomitant degeneration of the heart, valvular disease, or, per- 

 haps, upon a former carditis. The effect is very different when the 

 organ is enclosed within and adherent to a dense fibrous case, often 

 of the consistence of cartilage. Such a condition reduces the pro- 

 pulsive power of the heart in the very highest degree. The pulse be- 

 comes extremely small and almost always is very irregular. Dysp- 

 noea, cyanosis, and dropsy appear all the earlier, as the substance of 

 the heart is nearly always degenerated. Physical examination must 

 decide to what source disorders of the circulation are due. 



A lack of difference between the percussion-sounds during inspira- 

 tion and those during expiration has been given as one of the physi- 

 cal signs of pericardial adhesion ; but, whether heart and pericardium 

 be or be not adherent, the lung will still intervene between the latter 

 and the side of the chest with every deep inspiration, and, conversely, 

 will recede when a forced expiration is made. In this respect, then, 

 the signs will remain unaltered, unless, indeed, the outer surfaces of 

 the pleura and pericardium be grown together (Cejka). There is a 

 second symptom, of greater value. Sometimes, at the point whereat 

 we ought to feel the beat of the apex, instead of rising, we see the 

 intercostal space sink with every beat. This phenomenon we explain 

 as follows : The heart is shortened during systole, and a vacuum 

 would form, were not the space filled, either by the descent of the 

 heart or the depression of the intercostal space ; but, if heart and peri- 

 cardium be adherent, no descent can take place, hence depression of 

 the intercostal place must substitute it. This symptom is all the more 

 important, if, during diastole, we find the space rise again, when, upon 

 cessation of the systolic suction, the heart again becomes elongated, 

 and the apex returns to its position. This symptom, too, is often 

 wanting in many cases of pericardial adhesion. If the pleura and peri- 

 cardium be not adherent, the lungs may occupy the vacancy left by 

 the withdrawal of the apex during systole, and vice versa. 



On the other hand, a systolic depression of the region over the 

 apex may depend upon other causes than that of adhesion of the heart 

 and pericardium. If the latter be likewise attached to the spinal col- 

 umn, the lower half of the sternum will also be drawn down by the 

 systole of the ventricle. Moreover, according to Friedreich. in such 



