§ 158. B. Rheumatismus cordis. Endocarditis.

Either during an already existing rheumatism of the joints, or without any previous disease, the patients experience a sensation of heaviness in the left side of the chest, sometimes with fleeting stinging pains; in case a fever was present, it now grows worse. Distress of breathing, anguish, restlessness, palpitation of the heart, set in. The oppression sometimes increases to the most violent anguish and fainting fits; cough, with or without expectoration, sets in, the head and sensorium become affected, the features distorted, etc. Frequently nothing is seen except the exacerbation of the fever, and slight uneasiness. If a joint was swollen and painful, these local symptoms disappear sometimes suddenly, though this is not generally the case. The subjective symptoms being so uncertain and slight, the physical symptoms should be studied so much more carefully. At first, the percussion-sound is normal; not till hypertrophy and dilatation have set in, is the percussion-sound dull over a larger surface; the motions of the heart are more violent and hurried, sometimes irregular; hence the heart strikes the wall of the thorax with more force, and the palpitation is distinctly visible externally. The pulse of the extremities is frequently small, feeble, contracted, and not synchronous with the beats of the heart. The two sounds of the heart continue normal, but are more frequent and louder, or a murmur is heard with the first sound, which is generally more distinct in the left ventricle.

The inner membrane of the left ventricle is most frequently the seat of the disease; the endocardium becomes red, injected, or it exhibits opacities, thickenings, roughnesses, or actual exudations set in on the fibrous valvular tissue, leading to adhesions, diminution, ossification, and final insufficiency of the valves, from which result hypertrophy and dilatation of the right or left ventricle.

Sometimes, but much more rarely, the pericardium is inflamed. In this case the beats of the heart are at first distinct and violent; but if exudation in the pericardium take place, they grow feeble, and are scarcely perceptible, and the sounds are less clear and strong; as the exudation becomes more consistent on the surface of the heart, we distinguish a friction-sound, occasioned by the motion of the heart; the percussionsound remains normal, as long as the quantity of exuded matter in the pericardium is slight, but if it increases, the percussion-sound from the apex to the upper portion of the heart is constantly dull.

§ 159. The disease is met with most frequently in persons at the age of pubescence; organic defects of the heart, or former inflammations of that organ, are among the causes which, in articular rheumatism, incline to occasion a metastasis of the inflammation to the heart.

The disease runs a very rapid course, if we exclude the secondary affections resulting from it. The disease may terminate in dispersion, with the usual critical discharges by the skin and urine, or in metastasis to a joint, or to some other organ, the eye, for example, (which sometimes occurs with extreme rapidity,) or in hypertrophy and dilatation of the heart. Death scarcely ever takes place as a primary termination of the disease, except when pericarditis supervenes. Relapses occur easily, which fact alone renders the prognosis somewhat doubtful.

§ 160. The chief remedy, at first, is Aconite, when the restlessness, anxiety, and apncea are accompanied with increased action of the heart and blood vessels; when the motion of the heart is hurried and violent, the beats of the heart and pulse are not synchronous, and the patient complains of slight pressure in the left side of the chest, between the fourth and sixth ribs. The bold and frequent use of Aconite will frequently be sufficient to disperse the inflammation and prevent exudation and organic malformations. The physical signs indicating Aconite are: dulness of percussion-sound over a normal space, the motion of the heart is hurried, violent, (without raising that portion of the wall of the thorax corresponding to the heart,) the beats of the heart are not synchronous with the radial pulse; both sounds of the heart are still audible, without any murmur, except that they are more violent and louder, particularly in the region of the left ventricle.

Belladonna is suitable for general congestions of the chest and vascular excitement, with pressure in the region of the heart, arresting the breathing and occasioning anxiety; for unequal, irregular contractions of the heart, for violent constant palpitations of the heart, and occasional intermission of the beats of the heart. Belladonna quiets the most violent vascular excitement, vomiting, with fainting fits, and cold sweat over the whole body, fleeting stitches in the region of the heart, constant panting for drink, involuntary stools, and excessive anguish, with dilatation of the pupils. The lower attenuations should be used, and frequently repeated.

Cannabis is frequently useful after Aconite, when the violence of the vascular excitement has abated, when the patient complains of tensive aching pains in the middle of the sternum, with oppression of breathing, when the patient is tormented by nocturnal paroxysms of anguish, driving the patient from one place to another, and when he complains of violent shocks in the region of the heart on moving the body, with hammering from within outwards, below the costal cartilages, near the sternum, with violent palpitation of the heart, and sensation as if the heart were beating lower down. Cannabis may moreover act with benefit when the pericardium is involved, when morbid formations on the endocardium and valvular defects have taken place, when the percussion-sound is normal or else dull over a larger surface, when the sounds of the heart are strong, violent, or mixed with murmurs.