bad policy. While I believe the child in my case to have been dead when I first saw the case, and consequently not effected by the operation, I reflect that I could have saved the mother two hours' pain, and possibly might have saved the child had I have carried the forceps into the room with me. Second, when craniotomy becomes absolutely necessary, a common pair of sharppointed shears makes a good and safe perforator, and therefore equal to the best. There being no cutting edge exposed if ordinary care be taken to guard the point, there can be no danger to the mother, and the serious results we sometimes meet with, where the ordinary perforator has been used, are always avoided. And we should not allow ourselves to depend too much on any particular instrument in any case, but try if possible to meet and be equal to every emergency by grasping and utilizing any means of advantage that may be within our reach, and never under any circumstances sit down in the face of trying emergencies and wrap the gloomy mantle of perplexity about us and wish for this, that, and the other, when in many cases a very common thing can be quickly prepared that will answer the purpose, almost or quite as well, as the costliest instrument that is manufactured for that particular purpose.

Selections.

THE DIAGNOSIS BY AUSCULTATION OF PERICARDIAL FRICTION MURMURS.-The differential diagnosis of pericardial murmurs by means of auscultation is often a problem of the greatest intricacy, owing to the failure to recognize certain laws which pertain to the foundation of the auscultation of cardiac sounds and murmurs. In studying any case of possible pericarditis with with equivocal murmurs, it is always helpful to decide whether the etiological relations in a case favor the presence of pericarditis. This condition is rarely, if ever, present as a primary process, but it is frequently consecutive upon rheumatism or with

alterations of the blood-tissue, such as exist in renal processes, pyæmia, or it is secondary to acute or chronic inflammations in adjacent structures, such as the pleura, the peritoneum, the perihepatic tissue, and the mediastinal region.

The special object of this article is to direct attention to the differential diagnostic features of pericardial frictions in general, but especially of those varieties which acoustically closely resemble endocardial valvular murmurs.

In reviewing the causes which produce pericardial murmurs, Hayden has written of acute pericarditis: "I have never met with a case which would warrant me in asserting that a state of simple dryness and vascularity of surface may give rise in the pericardium to veritable friction sounds. I do not, however, deny the possibility of an occurrence which theoretically would seem not improbable. In every instance, without exception, in which I have had the advantage of determining by post-mortem examination of the body, the condition of the serous surface of the pericardium where friction sounds of indubitable pericardial origin had existed during the patient's last illness, I have found lymph in greater or less quantity effused upon the surface." Da Costa supports this statement, and theoretically grants that the initial stage of dryness of the pericardial membrane is associated with murmur, but adds that "practically, I have never seen it, and in the suspected cases, lymph has always been found, with the single exception of a case in which the friction sound had disappeared nearly a week before death, which resulted from kidney lesion, and where it was reasonable to infer that the lymph had been absorbed."

The attributes of a pericardial friction murmur are its quality, including loudness and pitch; its point of maximum intensity; the area of its diffusion, and its rhythm.

1. It is indubitable that the quality of pericardial friction murmurs may be distinctly rubbing or friction-like, and synchronous with the movements rather than the sounds of the heart, which characteristics lead Watson to assign the designation of to-andfro murmurs; bnt it is equally true that pericardial murmurs are sometimes blowing in quality, and quite indistinguishable

The su

accoustically from the endocardial valvular murmurs. perficial quality of the former murmurs afford a basis of distinction, while intra-cardiac valvular murmurs are audible, as though produced on a different and deeper plane. The rubbing sound will be apparent until the quantity of fluid becomes sufficient to separate the walls of the sac; the friction sound reappearing when the lymph is absorbed. The gradual disappearance of the murmur with a gradual reappearance is a fairly diagnostic sign.

The friction murmur may also be recognized by palpation. Stokes, indeed, looked upon the friction fremitus as separating pericarditis from valvular disease. A true pericardial friction fremitus is not limited to the known positions of maximum intensity of endocardial murmurs, but it may be felt over the præcordia, but not often beyond the normal limit of cardial dullness, unless there be associated inflammation of that portion of the pleura adjacent to the pericardium.

2. If it is granted that in cases of acute pericarditis the murmur is usually due to roughening of the pericardial surface by the presence of lymph, it becomes inferential that the continuous pulsation of the heart may reduce the roughness at one point of the pericardium, while fresh areas of roughness may be developed, and consequently the acoustic phenomena must vary, viz., the point of maximum intensity of the pericardial murmurs cannot always be the same. The friction murmurs must also cease if the fluid effusion becomes considerable, or adhesions of the pericardium may modify or entirely prevent the development of friction sounds. Occasionally bands of lymph have been found on post-mortem examination, stretched like a bridle over the heart across the pericardial sac, which must have favored the development of a murmur during life. When local adhesions of the pericardium permit portions of the free surface, more or less covered with lymph, to exist, the heart being free to move, friction sounds can occur which may be most intense anywhere over the præcordia, except at the points of adhesion. It is evident, therefore, that the location of maximum intensity must be a variable or shifting point, affording a conspicuous contrast to the

organic valvular murmurs, which have fixed centres of maximum distinctness, corresponding with a point at which the chamber of the heart where the murmur is produced, approaches most closely the chest surface. The usual location of friction murmurs, however, is over the heart or near the orifices of the vessels.

3. Special attention should be given to the area of diffusion of pericardial murmurs. It is an ordinary distinctive point that in endocarditis the abnormal murmurs are transmitted upon definite lines of maximum intensity; but in pericarditis one may recognize a very loud murmur, possibly simulating in quality an endocardial murmur, and yet its area of diffusion with maximum intensity is commonly limited to the præcordia, or if transmitted over the whole chest, as may happen in children, or in adults with cardiac hypertrophy, the area of maximum intensity of diffusion will follow some line which does not correspond with the area of diffusion of endocardial murmurs. The latter are transmitted with maximum intensity in a line which coincides with the direction of the blood current by which they are produced. Indeed, by closely observing the single point it may be possible to differentiate in the same case between pericardial and endocardial murmurs, as was illustrated by a recent autopsy upon a case in the Philadelphia Hospital. Lesions were found which had caused a double aortic and double mitral murmur, and also a pericarditis with adhesions which had given rise to pericardial friction murmurs. In this instance all these murmurs had been correctly analyzed during life.

4. The rhythm of pericardial frictions has been already noticed as to and fro, and synchronous with the movements rather than the sounds of the heart, yet the rhythm of pericardial friction murmurs may be systolic or diastolic.

5. A change of posture may increase the intensity of a pericardial friction murmur, rendering a murmur which is faint in the vertical, quite distinct in the recumbent position, while in endocardial murmurs usually the reverse prevails, that is, in those cases in which change of posture has any effect upon the acoustic phenomena of endocardial murmurs.

6. It should be borne in mind that certain postures give relief

to the dyspnoea of pericarditis when this symptom is prominent; for instance, if the recumbent posture on the left side is selected, the liver and heart both tend to exercise pressure on the pericardium, so that the posture on the right side is usually preferred. This symptom has, therefore, a relative value in estimating the etiology of a doubtful murmur.

7. The alterations common to the walls of the heart in encocardial valvular disease are absent, unless, indeed, endocardial processes are also combined.

In recognizing cases of endocardial murmur, we can estimate the gravity of the lesion rather by the changes in the auricle or ventricle of the heart than by the diffusion or quality of the murmur; but in pericarditis, these changes do not correspond with the hypertrophy and dilatations commonly found in endocardial valvular lesions; and when in uncomplicated chronic pericarditis, with adhesions, the heart is hypertrophied, the organ is apt to be drawn up to the left by the adhesions in a more or less significant manner.

8. Friction murmurs can be developed by the movements of the heart in the pleura adjacent to the inflamed pericardial sac, if the former be also covered with lymph. One of the best methods of differentiating this murmur from one developed within the pericardial sac is to cause the patient to cease breathing for a moment, and then by ausculting the heart the friction-sounds persist if of pericardial origin. If the portion of the pleura adjacent to the pericardium be also covered with lymph, the heart's motion transmitted through the pericardium may produce pleuritic friction even while the lung is at rest. The location of the murmur at the border of the pericardium and its transmission beyond its confines will be the best aids to auscultation; since, in pericarditis without associated pleurisy, the murmur will more probably be confined to the normal limit of cardial dullness, and the same rule will apply to a friction fremitus recognized by palpation.

A friction murmur can also be produced by the action of the normal heart in an inflamed and roughened pleura. This is very difficult to recognize with precision; the foregoing principles can