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The Heart Complications of Rheumatism

cardiac, acute, inflammation, structures, subacute, suffer and fibrous

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The cardiac apparatus is made up of the following structures 1. The hollow muscular substance of the heart, which by its con traction initiates the movement of the blood.

2. Rings of white fibrous tissue which surround and form the basis of the arterial and auriculo-ventricular openings, and to which the muscular fibres fire attached.

3. Fibrinous valves whose structure is continuous with that of the rings, and whose function it is to close the various openings of the heart, to resist the backward tendency of the blood, and keep it in the proper channel.

4. A membrane which lines the interior of the heart's cavities, and is reflected over the fibrous structure of the valves, and whose smooth surface facilitates the onward flow of the blood.

5. An investing membrane which covers the heart externally, and whose peculiar formation and smooth glistening surface facilitate the free action of that organ.

All these structures, with the single exception of the internal lin ing membrane, find their analogues in those which go to form a com plete and perfect joint. They are all apt to suffer in the course of acute rheumatism, though not all to the same extent.

The function of cardiac muscle, like that of voluntary, is to ini tiate movement. The function of the-fibrous structures of the rings and valves, like that of the fibrous tendons and ligaments, is to afford attachment to muscle, and to regulate normal and prevent abnormal movement.

The function of the pericardium, like that of the synovial mem brane of the large joints, is to facilitate free movements.

The eudocardium alone has no analogue in the structures of a joint.

When considering the action of the rheumatic poison on the joints we saw that the structures which suffer most are the fibrous textures which regulate their movements—the ligaments and tendons. It is the same in the heart. The structures which chiefly suffer are those which regulate the movement of the blood, the fibrous rings, and valves.

It is its tendency to affect the heart that imparts to rheumatism its gravest features. In the majority of fatal cases death is attributable to some form of cardiac inflammation.

Bouillaud was the first who insisted on the essential nature of the connection between rheumatism and this inflammation. Its frequent

occurrence in the course of that disease had indeed been pointed out by others before him, notably by Pringle. But it is to this distin guished French physician that we must accord the credit of having first insisted on the frequency and true nature of the heart affection. Before his time it was looked upon as a sort of metastasis, or retro cession of the inflammation from the joints to the heart. He re garded it as " one of the elements of the disease," and as early as 1835 advocated the view, which has since been generally accepted, that pericarditis and endocarditis are of frequent occurrence in the course of acute rheumatism, and are to be regarded as produced in the same way as the joint inflammation.

In all forms of rheumatism, acute, subacute, and chronic, the heart is apt to suffer. In the acute the cardiac inflammation partakes of the generally acute character of the attack and the symptoms are well marked from the commencement. In the subacute the symp toms are less marked, and the immediate result of the cardiac mis chief is less a source of anxiety. In the chronic its onset is so gradual that the cardiac affection seldom attracts attention until it is so far advanced as to cause serious disturbance of the heart's action, and the general symptoms of cardiac disease.

The exact proportion of cases of acute and subacute rheumatism during whose course recent cardiac inflammation occurs is differently stated by different observers. And the nature of the question is such that discrepancies must exist. In acute attacks the heart is more apt to suffer than in subacute, and young patients are more liable to this complication than more elderly ones. The acuteness of the attack and the age of the sufferer are thus important elements in determin ing whether or not cardiac complications are likely to occur. An observer the majority of whose cases are subacute, and the average age of whose patients is thirty, will have a smaller percentage of cardiac complications thail one who happens to have a larger number of acute cases, and the average age of whose patients is twenty.

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