Endocarditis.—Endocarditis usually appears at about the end of the first week, and often even sooner. But in childhood there are also cases, in which the endocarditis precedes the localization in the joints. Indeed endocarditis alone may be discovered, and only later when attacks of articular rheumatism follow, does the thought suggest- it self, that the heart disease may be of a rheumatic nature. In the very early period of childhood, such a course is apt to occur quite frequently (Schlossmann). The possibility that abortive articular rheumatism has existed must therefore always be borne in mind.
Pericarditis.—Next to endocarditis, pericarditis is an important and most fatal complication. The involvement of the pericardium too, is more frequent in children than in adults; it manifests itself in about 10 to 20 per cent. of all cases, being nearly always associated with endocarditis. It is by far the most frequent cause of death in children having rheumatism.
With serous or even serofibrinous pericarditis, a case of cor villo sum may develop, or a partial or complete obliteration of the peri cardium with injurious effect upon the heart action may follow. And it is just this combination of valvular defects and pericardial adhesions, together with a myocarditis which is quite natural in such cases, that may bring about a fatal termination to the disease, often so insidiously begun, after weeks, months or years of suffering.
Other Complications.--Pleuritis of a serous or serofibrinous nature is a complication which is not rare in chidlhood. Of course this occurs only in severe cases, and then only in combination with pericarditis. It is apt to be non-malignant, and even a considerable exudate may be readily absorbed. Other still rarer complications in childhood are bronchitis, pneumonia, and nephritis.
Angina and nose-bleeds in the course of articular rheumatism are often met with in children. Occasionally a purpuric rash appears in the neighborhood of the affected joints.
A peculiar relation hitherto unexplained, exists between chorea minor and the articular rheumatism of childhood. It may precede the joint disease, but in the majority of cases it follows it. Like articular rheumatism, it is often complicated by verrucose endocarditis, and like the latter, chorea seems, in some cases, to take the place of joint attacks. A more complete description of the phenomena may be found in the section on chorea minor.
As to the relation of erythema exudativum multiforme and ery thema nodosum to articular rheumatism I must refer to the respective sections in this book. Certain eye affections, more or less correctly classified as rheumatic, e.g., iritis, skleritis, cannot be discussed here.
Some conditions peculiar to childhood may be mentioned here. Severe psychical and nervous derangements, as hemi- and paraplegia and the so-called hyperpyretie form, which usually with a temperature of 411°-43° C. (105.4°-109° F.) leads to death, have been observed in childhood, hut only in very rare cases.
The localization of the disease in the joints of the cervical vertebra' often appearing with a rheumatic torticollis, is not rare in childhood; it is often misinterpreted as a purely muscular affection, as has been emphasized by Lannelongue and Malian. Sometimes it may be the only seat of the disease, resisting all therapeutic measures with a per tinacity unusual in childhood and may in this way lay the foundation for a subsequent chronic arthritis.
A form of rheumatism almost peculiar to childhood is nodular rheumuti:on, which was first described by Meynet in 1875 and obtained greater publicity through the writings of Rehn and Hirschsprung. Over 40 cases have been reported, mostly by English authors. It usually occurs in the course of an attack of a-cute articular rheuma tism, or sometimes during a relapse, generally in the third week or later from the onset of the joint symptoms. Subcutaneous nodules appear under the unchanged skin, developing very rapidly, often over night. They are more or less symmetrically located in the vicinity of the joints and along the tendons but may be in distant parts of the body, e.g., on the bones of the skull. They are the size of a pin-head, or even a nut, and only rarely are firmly attached to the periosteum or tendons. They are rather sensitive to pressure and consist of fibrous, or partly fibro cartilaginous tissue (Henoch, Hirschsprung, Barlow). Drewitt considers them analogous to the nodules of rheumatic endocarditis. Their num ber varies from one to more than fifty. The nodules generally soon disappear. Rarely their re-absorption extends over weeks or months in the severer cases of rheumatism, which are almost always compli cated with endo- or pericarditis. Some cases with chorea were repeat edly observed and one case had also erythema multiforme.