Clinical Remarks on Acute Rheumatism followed by Pericarditis with Effusion: Recovery
Authors: J. D. Heaton
Journal: BMJ (1872)

He had had good health till the present attack of acute rheumatism.Condili/on on Admnission.-He had much pain in the shoulders, elbows, and hands, andl considerable loss of power in the arms ; some swelling and redness of the knuckles; no pain in the chest, nor sense of palpitation ; slight cough.Pulse go; bowels costive.A loud rough systolic single murmur was heard at the base of the heart, attributed to defect in the aortic valves.No other morbid sound wvas then recog- nisable.He was order-ed to have a colocynth and calomel pill imme- diately, and an ounce of the following mixture every six hours: R Potassac bicarboni. 3ij; sodas potassio-tart.-ss ; spiritlds ether.nitr.3iij; aqux menthce zviii.I'.December 30tl.To-day, a dlouble " to-and-fro" sound was heard over the base of the heart, having a superficial character, very different from the single murmur hieard yesterday, and unquestionably a friction- sound.The patient had nio pain in the cbest, where he asserted he was " all right".TIhe heart's action was rather excited.The pain ard incapacity in the arms remained unclhanged.A blister was applied over the heart; and 3iss of tincture of digitalis was added to the mixtul e. December 3ist.There was distinct dulness of stroke sound in the cardiac region, from the fourth rib downwards, for between three and four inches; and from the left margin of the sternum three inches to the left.The char-acter of the murmur was not materially changed.Tem- perature 102 deg.January Tst, 1872.The evening temperature rose to 104 deg.January 4th.The temperature had fallen to 102 deg.The area of dull stroke-sound was somewhat diminished.The character of the murmur was altered, there being now only a single systolic sound, similar to that heard at the first examination.The general symptoms and appearance were improved.There was still much complaint of pain and loss of pow er in the arms.IHe had no uneasiness in the chest.January 7th.The patient was so much improved, that it was thought safe to remove him, in a wheeled ambulance, to the medical ward, in which previously there had been no vacancy.The removal was effected with every care, but was followed by a serious relapse.On the 8th, the temperature, which had fallen to Ioo, rose to 101.5 ; and on the gth, to I02 deg.; the pulse not, however, rising above loo.The area of dull stroke-sound was inicreased hoth upwards and downwards.Ie was restless, could get no sleep, and had a hag- gard expression.Ile had a short tr-oublesome cough, btit no dvspn(rsa; no pain in the chest, nor any uneasy sensation there.ITe was ordered to take one of the following powders every six hiours 9 Pulv.ipecac.comp.9ij ; calomel.gr.vj.M. Divide in pulveres vj.On the iIth, the effuision lad much increased; the dull stroke-sound reached upwards to the clavicle.There was little murmtiur audihle.Pulse 98, feeble, quite regtular.The patient looked haggard and prostrate.Ile said he felt worse ; but he spoke vith a firm voice.There was no thoracic pain, nor oppressive dyspncea.The bowels were relaxed ; the gums rather tenider.The p)owder was ordered to be taken at bedtime onily, and the mixture to be omitted.He was ordered to take the following dratight every six hou-s : It l'otassii iodidi gr.v; potass.cbicarb.gr.xv tinct.camph.comp.ss ; aquae j.WI.A blister wvas applied below the clavicle.January 13th.There was a great improvement in his appearance;he slept well last night.Temperature ioo deg.There was a finger's breath of resoiiance below the clavicle.January i4tb.There were tw'o inclhes of resonance below the clavicle.Temperature 98.5 deg.Ile lay chiefly on the left sidle.The bowels were still relaxed ; the gums swollen and tender.Ile was ordered to omit the powders, and to take one of the followinig pills every six hours:Rc Morph.acetat.gr.j ; extracti papav.gr.xxv.Ml.Divide pilulas vj.From this date to the 20th there was daily improvement.The car- diac dulness retreated within its proper limits.The pulse ranged be-