Historical Milestone

Rheumatic Pericarditis (Broughton, 1827)*

SAUL JARCHO, M.D.

New York, New York

D ESPITE the resources and refinements of contemporary medicine the diagnosis of

pericarditis often proves to be difficult. Let us see how the problem was approached by a British army doctor a century and a quarter ago in the days of King George IV.

Samuel D. Broughton (1787-l 837), after having studied medicine at St. George’s Hos- pital, became assistant surgeon of the Dorset- shire militia. Subsequently he was assistant surgeon and then surgeon of the Second Regi- ment of Life Guards. He took part in the Napoleonic Wars in France, including the famous Peninsular Campaign, and described his experiences in a volume published in 1815. He also served with his regiment at the battle of Waterloo. His principal writings deal with physiology, toxicology and forensic medicine. He was a fellow of the Royal Society. He died in 1837 after an amputation for a traumatic lesion of the ankle.

Broughton’s paper, reproduced herewith, appeared originally in the London Medical and

Physical Journal, n.s., 3 : 508-511, 1827.

* * *

BROUGHTON’S CASE REPORT (1827)

Case of Pericarditis, connected with acute Rheumatism, successfully treated by S. D. BROUGHTON, Senior Surgeon to the St. George’s and St. James’s Dispensary, and Surgeon to His Majesty’s second Regiment of Life Guards.

The case of which I am about to give an account, though one now well known and understood, may nevertheless be regarded as a useful addition, per- haps, to the general stock of information upon the subject to which it relates.

It will be observed that the metastasis of acute

rheumatism was the obvious exciting cause of an inflammatory affection of the heart, that the alterna- tions of the disease in the different structures which it involved were strongly marked and clearly trace- able, and that the mind was affected in a singular manner during its progress.

The case terminated favorably; which, in conjunc- tion with its unequivocal signs, I deem to be not the less interesting to the pathologist on that account.

A recruit of the Life Guards, recently from the country, aged nineteen, tall, but of rather a slender form and pallid complexion, was taken into the regi- mental hospital on the evening of the 3rd of April, 1826. He complained of pains throughout the body, principally referred to the joints. The tongue was white, the pulse full and quick, the skin dry, and the bowels were moderately free. I prescribed seven grains of James’s powder with three of Calomel; and placed him on spoon-diet, with barley-water and nitre.

April 4th. The skin appeared moist. but the ac- tion of the pulse was little diminished. One drachm of the Vinum Antimonii Tart. was given in a saline draught every six hours. The powder was repeated, and an aperient draught of salts and senna ordered in the morning . . . .

6th. Some degree of inflammation of the pharynx. A gargle of Nitrate of Potass prescribed, and the mixture repeated. Calomel and Antimony as before.

7th. Some increase of fever, and return of pains in the joints occurred today, and he was put into a hot bath. The antimonial wine excited too much nausea. The dose was decreased, and the mixture given every four hours, with ten grains of James’s powder every six. The Calomel omitted. Sore- ness of the pharynx relieved. Next day, he appeared to be much relieved, with moisture on the skin, and less fever.

9th. He experienced great pain and tumefaction of the knee and ankle on one side, with extreme tenderness to the touch. Bowels open; tongue furred. I ordered half a drachm of the Colchicum Wine to be given with each dose of the mixture, and

* Based on research assisted by the National Institutes of Health (GM-06392j.

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ten grains of the compound powder of Ipecacuanha, erate draught of Salts and Senna given. In the with six of James’s powder, every six hours; and a evening, he was very much relieved. The blood fomentation of poppies to be applied to the limb. appeared much cupped and buffy.

10th. The pain and swelling of the limb was much relieved, and now an urgent cough and fixed pain at the sternum appeared. The tongue was very dry and furred; the pulse hard, rapid, and full. A deep inspiration excited pain and coughing, indicating acute inflammatory action, probably in the peri- cardium. The respiration did not seem to indicate the lungs as the seat of the disorder. Twenty-four ounces of blood were directly taken from a large ori- fice in the arm; the Colchicum was omitted, and the Antimony increased to double the former dose. Ten grains of James’s powder, with two of Calomel, were given in the evening; and thirty leeches applied to the chest, the bleeding in the morning not having removed the pain, although it had diminished the fever, and the heart being felt acting powerfully against the ribs. The blood taken in the morning was much cupped and buffy. A blister was applied to the back, between the shoulders, at night.

20th. The pulse was much reduced, and he was better, and continued so, but weak, till the 25th, when a iixed pain in the left side came on, not in- creased by a deep inspiration. The pulse rose to 116, but without cough. Twenty-four leeches were applied to the side, and twenty drops of the Tincture of Digitalis added to each dose of the mixture. One drachm of Colchicum-wine was given at night . . . .

27th. Pain returns periodically in the region of the heart; the pulse was bounding and intermittent, and the heart acted forcibly against the ribs, as if struggling in a confined space, with a sensation of fluttering in the chest. When on his back he com- plained of suffocation, and respired best in an upright position. Slept well last night. The tongue was moist and clean. No stool today. The Colchicum omitted. The mixture continued, and thirty-drops of the digitalis given at each dose. An opening draught. . . .

11 th. Some relief from the urgent symptoms of the day previous seemed to be obtained, but the action of the heart and arteries continued high and strong. The tongue was more moist, and less furred. The wrist of the left arm was swollen, red, and tender, and there was pain in the shoulder when moved. He had rather a restless night, but the skin was moist. The application of the leeches was followed by a dis- position to syncope. The cough was considerably diminished, and the bowels were open. The pulse the evening before was at 130, but diminished in strength. The urine was very turbid, but clear this morning ; and the swelling of the limb went down after the application of poppy fomentations, but remained stiff. Twenty drops of the Tincture of Digitalis were added to each dose of the mixture . . .

29th. Pulse sixty, and did not intermit; urine high coloured and clear; restless. This day he ap- peared confused in his mind, and talked incoherently. Pergat.

30th. The incoherency continued, and he re- peated the last word of every question and remark made to him. The extreme fulness and force of the heart’s action somewhat lessened. The mixture repeated, and the blister renewed between the shoulders.

13th. Passage of urine free; bowels open. The cough was nearly gone; pulse reduced to eighty- four. Slept well. Tongue moist and clean; the left arm much better; skin moist.

14th. This morning the cough had somewhat increased, but the pulse continued at eighty-four. Complained of ardor urinae, for which twenty drops of the Liquor Potassae were given in barley-water and solution of gum arabic occasionally, together with ten grains of the compound powder of Ipe- cacuanha every six hours.

May 1st. He appeared to have recovered his self- possession, and to have nearly left off repeating the last word addressed to him. Slept better last night, and was more composed. He respired easily: the pulse was less full; the heart beat less forcibly, but the artery pulsated irregularly. Tongue moist and clean, and bowels open. During the few follow- ing days, he appeared to improve, but rambled a lit- tle, and sometimes the repetition of the last word was observable, and his spirits appeared low. The pulse was reduced to fifty-six, and the heart’s action dimi- nished. The artery at the wrist intermitted in its beats. Latterly his mind seemed less affected. On the 4th, the Digitalis and Antimonial Medicine was omitted, and a draught of Infusion of Roses, with Epsom Salts, given thrice a day; and his diet was rendered more generous, in a small degree.

15th. Pulse eighty-four. The ardor urinae re- lieved, and the urine, which was thick yesterday, is now clear. The bowels were open, and he was better in every respect. The Digitalis omitted . . . .

19th. Pain of the chest and cough returned;

9th. The intermission of the pulse continued, but less so, and he seemed to complain only of debility, with less restlessness and mental affection.

pulse rose to 120, and rather full; tongue dry. Twenty-four ounces of blood taken from a large orifice in the arm. Diet reduced to spoon. The mixture, with one drachm of antimonial wine, re- peated every four hours. The Dover’s powder omit- ted. A large blister applied to the chest. A mod-

19th. Has sat up every day, and, when upright, the pulse beat steady and at 100, but not strong or full. Night sweats have come on, but he has slept well, without pain or cough. The heart’s action continued quick and forcible. Since the lbth, he had taken a grain of Digitalis with three of the Pil. Hydr. twice a day, and yesterday the Digitalis was increased to a gram and a half. The following pills were now prescribed: Digitalis gr. v.; Hydr. Subm.

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Jarcho

gr. v.; Extracti Conii zj. M. fiat pil. xv. quarum sumat ; ter in die. An ointment of one drachm of Tartarised Antimony, rubbed up with an ounce of the Ung. Cetacei was applied every night to the chest, till the pustules produced rendered its omission nec- essary. He continued to gather strength, and the pulse became slow, natural, and equable; and on the 24th of June he left the hospital, and returned to his duty, having been under treatment since the 3rd of April. He has since continued perfectly well, and has never relaxed from his duties a single day. On examining him recently, I found the heart seemed to labour against the ribs: but his health was ex- cellent, and his constitution in good condition, his conduct being steady, sober, and quiet.

COMMENT ON BROUGHTON’S PAPER

The patient was a 19-year old country boy recently recruited into His Majesty’s Second Regiment of Life Guards. He was taken sick in the spring, the favorite time of onset for acute rheumatic fever. The presenting complaint consisted of pains throughout the body, chiefly in the joints. On entry into the regimental hospital the patient was found to have white

( i.e., coated) tongue, rapid pulse and dry skin. The bowels were “moderately free.” No further details of the physical condition at this time are given. Three days after admission the presence of pharyngitis was recorded. On the seventh day the patient had tenderness, pain and swelling of the knee and ankle. On the eighth day he had an urgent cough and fixed pain at the sternum. Deep inspiration pro- duced pain and cough; this was interpreted, correctly, as evidence of acute inflammation. The inflammation was thought to be in the pericardium because the pain was referred to the sternum and because there was no disturbance of respiration such as might be expected if the lung or pleura were diseased. Subse- quently the left wrist became swollen and the shoulder hurt when moved. On a still later occasion it is noted that the heart acted forcibly against the ribs, “as if struggling in a confined space.” This suggests that the apical beat was at least inspected, and it may have been palpated also. The patient complained of suffocation when supine ; he breathed best in an upright position. On about the twenty- seventh day he began to talk incoherently and to repeat the last word of every question and remark made to him. The psychic symptoms lasted about 11 days.

After a conscientious course of treatments characteristic of his time and no less bewildering

to ours, he recovered. He had been bled, purged, blistered and leeched, and had taken calomel, antimony, colchicum, digitalis, James’s febrifuge and Dover’s useful powder of opium and ipecac. In an undated follow-up note he was reported to be well and on regular military duty. His heart seemed to labor against the ribs, but his constitution was unimpaired. His psyche was in good order, and his conduct was steady, sober and quiet.

Broughton refers to the disease as one “now well known and understood.” In support of this confident or complacent remark he states that in the case under study the metastasis of acute rheumatism was the obvious exciting cause of an inflammatory affection of the heart and that the alternations of the disease in the different structures which it involved were strongly marked and clearly traceable. Al- though full recognition of the valvular and other cardiac lesions consequent on acute rheumatic fever is justly credited to Jean-Baptiste Bouil- laud (1836, 1840), much was already known in 1827 when Broughton published his case report, and this body of knowledge must be credited in part to such famous men as Baillie and Pitcairn and in part to unrecorded observers.’

It must be granted that Broughton evidences a general understanding of the natural history of acute rheumatic fever and that in this respect his knowledge was equal to that possessed by the best physicians of his day. However, when we come to study the clinical technics which he used in the study of his interesting patient, we find that he makes no mention of percussion or auscultation. This, it will be noted, was in 1827, 66 years after Auenbrugger published the Inventum Novum, 19 years after Corvisart pub- lished his revival of percussion, and 8 years after Laennec issued the first edition of his epochal Treatise on Mediate Auscultation.

It is observable, therefore, that Broughton’s report shows greater retardation (or “cultural lag”) in physical diagnosis than in pathology. In this respect it resembles much of the British and American clinical writing of the time. Per- haps the explanation lies in the fact that Baillie, Pitcairn and other early modern students of the pathology of rheumatic fever came from the British Isles, whereas percussion and mediate auscultation originated on the Continent.

Without the evangel of the newer methods, Broughton and others similarly circumstanced made their diagnoses by reasoning from symp- toms. They derived incidental assistance from

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keen inspection and from rather limited use of acute rheumatism might go to the heart, the palpation. In the case of the young recruit diagnosis of pericarditis was made with apparent the essential components of the diagnosis were ease. (1) acute rheumatism of the joints, (2) cough and constant sternal pain elicited by deep in- REFERENCE spiration, and (3) absence of the respiratory disturbance which would be expected in pneu-

1. JARCHO, S. Rheumatic carditis: Bouiliaud and

monia or pleurisy. Since it was known that some unknown Irish precursors. Am. J. Cardiol., 1: 514, 1958.

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