Diseases of the chest and the principles of physical diagnosis . o hydropneumothorax, or to hydropneumo-pericardium. Hepatic murmurs may be heard over the liver or in the epigastriumin some (rare) cases of hepatic cirrhosis. They are generally venous inorigin (blood flowing from small into larger veins, or sinuses) and maybecontinuous or intermittent in character. PERICARDIAL FRICTION SOUNDS In the early stages of pericarditis the serous membrane whichis normally smooth and moist becomes roughened as a result of con-gestion and exudation. The exudate, instead of noiselessly gliding overthe nei
Diseases of the chest and the principles of physical diagnosis . o hydropneumothorax, or to hydropneumo-pericardium. Hepatic murmurs may be heard over the liver or in the epigastriumin some (rare) cases of hepatic cirrhosis. They are generally venous inorigin (blood flowing from small into larger veins, or sinuses) and maybecontinuous or intermittent in character. PERICARDIAL FRICTION SOUNDS In the early stages of pericarditis the serous membrane whichis normally smooth and moist becomes roughened as a result of con-gestion and exudation. The exudate, instead of noiselessly gliding overthe neighboring pericardium, now produces a rough, scratching or scrap- 256 THE EXAMINATION OF CIRCULATORY SYSTEM ingsound,similar in quality to that heard over an inflamed pleura. Thissound is known as a pericardial friction. It often has a dry, creakingor shuffling, leathery quality, is heard during both systole and diastoleand is therefore described as being to and fro. It is frequently ac-companied by local pain, seems close to the ear and is intensified by pres-. FiG. 214.—Acute sero-fibrixous pericarditis. The pericardial sac is stretchedandhas been greatly distended by serous exudati. Both the mural and the visceral surfaces arecovered with fibrinous exudate (cor villosum, bread and butter pericardium). Such a heartwould yield loud friction sounds in the early stages of inflammation. Later when theserous surfaces were separated by liquid effusion the friction would disappear, except per-haps at the base, while the heart sounds would be muffled and distant. {From XorrisCardiac Pathology.) sure. It remains localized, isnot transmitted in the directions character-istic of endocardial murmurs, and is often loudest over the middle of theprecordium where the heart is uncovered by lung tissue. It may be dif-ferentiated (1) from a pleural friction by the fact that it is synchronous HEART MURMURS 257 with the heart, and not with respiration and that it does not disappearduring the Val
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