388 PERICARDITIS. 



no doubt that pericarditis exists : other indications of inflam- 

 matory action will not be wanting, but here there is less 

 need for the evidence of correlative symptoms than in other 

 cases. When friction-sound is absent, it may be annulled 

 either by the presence of fluid, or by universal adhesion ; in 

 either case, the general symptoms must be decided before we 

 can be warranted in pronouncing such a diagnosis. Along 

 with these, not in opposition to them, we shall find in the 

 former very extended dulness, especially in an upward direc- 

 tion, and, as usually described, assuming somewhat of a pear- 

 shaped form; undulatory movement may sometimes be visible 

 over the prsecordial space, while the heart's action is excited, 

 laboured, or irregular, and the apex-beat somewhat elevated; 

 the ordinary sounds of the heart are distant and indistinct over 

 the position of percussion dulness, becoming louder and more 

 natural above the space occupied by the fluid ; tenderness 

 over the praecordial space, pain, and dyspnoea, and great 

 distress from any sudden movement, are also met with in 

 such cases. On the other hand, when the surfaces are agglu- 

 tinated together, the evidence is more obscure ; perhaps the 

 most important points, when taken in connection with the 

 general symptoms, are persistently perverted rhythm with 

 nothing else to account for it, and a certain degree of obscu- 

 rity of sounds, accompanied by increased and excited action. 

 When, along with these, there are also praecordial pain, dis- 

 tress or anxiety, and dyspnoea, the diagnosis may be pretty 

 certain in a case of acute rheumatism or severe pleurisy, 

 where pericarditis is to be looked for, but can never be relied 

 on when there is nothing else to guide us to it. 



" In the early stage, excited action, altered rhythm, and 

 creaking noise before friction is established, should prepare 

 us for its appearance, especially if pain occur in the course of 

 rheumatism, pleurisy, or albuminuria. In the latter disease, 



