In endocarditis the morbid appearances, when not congenital, are limited almost invariably to the left side of the heart. The valves become thickened and softened, and very soon granular on the surface. The granulations enlarge and develop into the so-called vegetations — out growths from the fibrous tissue of the valve which may vary greatly in shape and size. They consist of connective tissue more or less perfectly organised. They are usually limited to the auricular surface of the valve, and are often partially covered by fibrinous deposits. Granulations may also develop on the chordee tendinem The softened tissue of the valve may tear, or the chordm tencline may rupture ; and the tension of the valve and the closure of the orifice may be seriously interfered with. After a time the valves may become thickened, contracted, and hardened. Sometimes they adhere to one another or to the wall of the ventricle. In this way, also, the proper closure of the opening may be impossible, and the opening itself may be narrowed and altered in shape.
Ulceration may take place, seriously affecting the valve itself, and tend ing to produce other grave consequences. It is the washing into the cir culation of fibrinous deposits and particles of disintegrated tissue from the ulcerated surface that produces embolism in distant organs—the brain, the kidney, or the spleen.
Symptoms.—The disease begins suddenly. The child, if old enough, complains of cold, and sits over the fire. He is unwilling to move about, sometimes vomits, and may feel some stiffness of the articulations. Soon, pain is complained of in one or more joints, and the child takes to his bed. When the patient comes under observation his temperature is moderately high-102° or 103°. His skin is generally moist with a sour-smelling per spiration, and on inspection we find the affected joints tender, swollen, and suffused with a pink blush. The child is thirsty, has little appetite, and his tongue is furred. The urine is high-coloured and scanty, and is often thick with lithates. The bowels are confined. The patient may wander at night ; he sleeps badly on account of the pain ; and for these reasons (pain and want of sleep) his face is often haggard-looking, and his expression distressed.
The pain is at first of only moderate severity, but gradually grows worse. As long as the child is quiet and undisturbed he may not make much complaint ; but if the limb is touched, or the bed is shaken, he at once shows signs of distress. The degree of pain and the amount of swell ing around the joint seem to bear no relation to one another. The artic
ulations affected are usually the larger ones—the hips, the knees, elbows, ankles and wrists. It is exceptional for the small joints of the fingers and toes to be painful and swollen. Usually one or two joints are first attacked ; these recover, and others become inflamed. The whole illness may last a variable time, but the duration of the inflammation in each particular joint is comparatively short. It may pass away in a few hours, and rarely lasts longer than a day or two. Sometimes, after leaving a joint and passing to another, the inflammation returns to the joint first affected ; and in this way, if the illness be a long one, the same joint may be at tacked again and again before the energy of the disease is exhausted. Even when the attack appears to be at an end, a sudden return of the symp toms may distress and disappoint the patient and his friends. Relapses are very common in rheumatic fever, and the symptoms may return, after a more or less complete subsidence, two, three, four, or even five times.
The articular inflammation, although the part of the disease which causes the greatest discomfort to the patient, is yet, as it seldom produces after ill-consequences, of comparatively trifling moment. A far more im portant feature is the heart affection, which is so common an expression of the malady. Inflammation of the fibrous structures in and around the heart is an essential part of the disease, as it attacks young persons, and must not be regarded as a mere casual complication. In exceptional cases, indeed, a child may have rheumatic fever and the heart may escape ; but in rheumatism all the fibrous structures of the body need not be af fected •at once. The patient may have inflammation of one joint and not of another ; the right wrist, for instance, may be affected and the left may escape ; one leg may be crippled and the other sound. So the disease may attack the joints and leave the heart alone, as it may attack the heart and spare the joints. The younger the child the more likely is it that the disease will fasten upon the heart to tht exclusion of the articulations.
The occurrence of rheumatic inflammation of the heart and pericardium is not at once announced by any striking change in the symptoms, or even in the aspect Of the patient. Indeed, it is matter for surprise how complete in most cases is the absence of all external indications that so important an addition has been made to his illness. Often the only sign of implication of these organs is derived from physical examination of the chest.