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Rheumatism Case

heart, symptoms, delirium, acute, death, blood, vessels, loaded and fibres

RHEUMATISM CASE Xil. —"A boy, aged 12 years, although of a delicate frame, had enjoyed generally a good state of health. On Saturday, the 20th of April, he was apparently quite well, having been on that day on a visit to one of his relations by whom this remark was made. On the next morning he was brought to the Infirmary, discovering at that time the usual symptoms of fever, namely, great bodily heat, a quick pulse, the tongue white and much furred. On the next day (Monday), his fever was much increased, but the only pain of which he complained was in the left thigh and knee, which ceased before night; in the afternoon he became delirionS with much watchfulness. On Tuesday the delirium was very considerable, but without any comatose tendency : the pupil of the eye much dilated, but not in sensible to light. He complained but little of pain, but when closely pressed upon the subject he pointed to his forehead. Early in the afternoon of that day he had a convulsive fit which soon went off. In the evening all his symptoms became aggravated, and he passed the night almost without sleep. On the following morning he ap peared much sunk; his breathing for the first time became difficult. He was then sufficiently sensible to answer any question put to him, but soon afterward he became insensible, and gradually declined till about two in the afternoon, when he expired." Those who saw this boy thought that his symptoms were of cere bral origin, and " that there was effusion within the head." The idea of there being anything the matter with the heart did not suggest itself to his attendants : and "at no period of his illness did he complain of pain iu any part of the thorax, nor was there any irregularity, either in the action of the heart or pulsation of the arteries." It having been considered from the general character of the symp toms that the cause of death was to be sought in the head, this was the part first inspected: "but after an attentive examination of the brain, nothing farther could be remarked than that the vessels were generally turgid; not more so, however, than is frequently seen when death has taken place under circumstances that lead to no suspicion of affection of the head." The abdomen was healthy. So were the lungs.

" On opening the pericardium it was found to contain between four and five ounces of turbid serous fluid, and flakes of coagulable lymph floating in it. The internal surface of the membrane, both where it constituted the exterior bag, and the reflected layer upon the heart, was covered in various situations with a thin layer of lymph exhibiting a reticulated appearance. The size of the heart was natu ral in relation to the age of the patient. Upon cutting through its parietes the fibres were exceedingly dark colored, almost of a black appearance. This evidently depended on the nutrient vessels being

loaded with venous blood. The fibres were also very soft and loose in their texture, being easily separable, and with facility compressed between the fingers. Upon looking closely to the cut surface ex posed in the section of either ventricle, numerous small collections of dark-colored pus were visible in distinct situations among the muscu lar fasciculi. Some of these depositions were situated deeply, near to the cavity of the ventricle, while others were more superficial, and had elevated the reflected pericardium from the heart. The muscular fibres of the auricles were also softened in their texture, and loaded with blood, but without any collections of pus between them. All the cavities of the heart were loaded with coagulated blood. The internal lining, valves, and every other part of the organ exhibited nothing worthy of remark, except the state of general turgescence in the capillary vessels, which had also extended to the lower part of the trachea, bronchi, etc." This case serves well to show that we may have inflammation of the muscles of the heart, sufficiently severe to cause death in a few days, without a single symptom to call special attention to that organ.

It also indicates, though in an unusually marked manner, the character of the general symptoms on which we have to rely for a diagnosis. There are absolutely no physical signs by which the exis tence of myocarditis can be determined. There may be indications of cardiac weakness, the impulse may be diffuse or the apex-beat im perceptible, and the first sound muffled or indistinct—but this is not enough for a diagnosis. It is to the general symptoms that we have to trust; and these are essentially the indications of nervous distur bance—mainly delirium.

Delirium in acute rheumatism is always a symptom of serious import. It is so because of the serious nature of the complications of which it is symptomatic. It occurs (1) in hyperpyrexia; (2) in myocarditis; (3) in pericarditis, and (4) in pneumonia, arising in the course of acute rheumatism.

In hyperpyrexia there is the thermometer to guide and give pre cision to our diagnosis. In pericarditis and in pneumonia equal pre cision is obtained from a physical examination of the heart and lung. But in inyocarditis we have no such aid, and we have to trust to the general symptoms only.

It may be stated generally that delirium arising in a case of acute rheumatism complicated neither with pericarditis nor pneumonia, and in which the temperature is not over 105°, is symptomatic of myocarditis. The delirium may be acute, generally it is low and muttering. With it there are sometimes noted muscular tremors which may give to the patient somewhat the appearance of one suffer ing from delirium tremens.