In the progress of rheumatic fever it is the duty of the medical attendant to examine the condition of the heart at every visit. No fact is better established than the association of cardiac inflamma tion with this disease ; and if remedies can avail, the time for their employment is at the first inroad of the inflammatory action ; the organ once spoiled is seldom restored to a perfectly healthy state : it is perhaps therefore not out of place to say a few upon the subject of the precursory or premonitory phenomena, as they may be called. It would appear that when the perspira tion is less abundant, and less sour-smelling, when the skin is dry and the odor rancid, the liability to cardiac complication is greater. The pulse is sharper and firmer, the heart itself becomes excited, its systole is sharp and shrill, and its impulse against the chest more perceptible, when there is any tendency to inflamma tion of that organ : but this excitement may be calmed, and no further change observed. Next we find that there is some altera tion in rhythm; the 1st sound seems to be shorter, and the 1st interval longer than in health; at least there is a notable change in the proportionate duration of the lst and 2d sounds and the lst and 2d intervals; this, too, may subside, but is very liable to be followed by more decided evidence of inflammation. Pain or dyspncea may occur before friction or bruit of asy kind, but they seldom precede the other indications, and ought not to be the first suggestion of cardiac complication. If after the changes just spoken og a slight creaking be heard, we may be sure peri cardial friction is just about to show itself; if a slight rough ness of the 1st sound at the base, that endocardial murmur will soon be detected.
Not nnfrequently the cardiac affection the consequent changes in the sounds of the heart, have been developed before the patient comes under observation; and it is important to be able to determine what is the exact condition of the organ at the time of examination. The following rules may be laid down for the guidance of the student:— a. When pericardial friction exists, the case is clearly one of pericarditis.
b. When an endocardial murmur is present, it is well to inquire whether the patient have ever previously suffered from rheuma tism, or have had any symptoms of disease of the heart before his present attack.
e. A systolic, aortic, or mitral murmur, as already described, found in a first attack of acute rheumatism, with no evidence of enlargement or irregular action, is very probably the result of recent endocarditis.
d. A murmur heard on the first examination of the heart in a second or third attack of acute rheumatism, or along with en largement and irregular action, or when there is a history of pre vious palpitation, dyspncea, or dropsy, is not to be regarded as evidence of endocarditis, which can only be inferred from con comitant symptoms.
e. When pain and dyspncea are complained of, and yet no mor bid sound can be detected, the pericardium may be full of fluid. In such circumstances it will be observed that the natural sounds of the heart are obscure and distant in theprEecordial region, but become clear and distinct above the base of the heart ; the dulness is manifestly extended, especially upwards, and its pyriform shape may perhaps be made out, or undulatory move ment may be seen. The action of the heart is excited and in
ereased, or irregular; and this forms a striking contrast to the weakness of the sounds.
f. In rare cases, universal adhesion of the pericardium may have annulled the friction-sound. This circumstance is to be borne in mind when the evidence of previous inflammation is distinct and the sounds of the heart are modified in a way that we cannot otherwise account for, especially when there is persistent alteration in rhythm. There is probably no combination of signs specially diagnostic of the condition here referred to.
The distinction between endocarditis and old valvular murmur is very con stantly lost sight of; without any further question, a bruit is at once held to be conclusive evidence of inflammation. This is a very grave error in diag nosis, because, as we regard pericarditis and endocarditis as something differ ent from the blood-change of rheumatic fever, and as of much more serious import to the patient's health and life, we are justified in disregarding the rheumatism, and trying at all hazards to save the central organ from damage ; but such treatment is never to be adopted without reason, and is calculated to be injurious when based on a mistaken view of the case. At the same time it is to be borne in mind that a valve once thickened by inflammatory action shows a remarkable proclivity to future attacks, and at a post-mortem examination often exhibits fringes of fresh lymph, the symptoms during life were scarcely such as would have justified, even if they had suggested, the diagnosis of endocarditis.
The harmony of general symptoms and physical signs has been much in sisted on in the preceding pages, because the blood-change that occurs in association with what we call rheumatic fever is unquestionably one that tends towards anemia, as is proved by the development of blood-sounds during its continuance, which were not heard previously—a circumstance not observed in true inflammations, as the term is generally understood. To apply deple tory measures when an anemic murmur is heard, is surely what no experience would justify or recommend.
The most trustworthy indications of the liability to inflammation, or of its actual existence, are to be found in altered rhythm and persistent excitement, if by this term we understand something different from increased action. It is that which is found in its simplest form in nervous palpitation •, and the student should make himself familiar as soon as possible with the difference, which is by no means difficult to recognize, between the character of the sounds as they are heard in the excitement of nervous palpitation, the in creased action of hypertrophy, and the quickened movement of fevers and inflammations of other organs.