There is one accident which sometimes occurs as a direct result of en docarditis. The vegetations on the inflamed valve may undergo disinte gration, and minute particles swept away into the general circulation may become arrested in the small arteries of a distant organ. Ulcerative en docarditis is not a common disease in children, but it is occasionally met with. This complication gives rise to symptoms which may be mistaken for those of pytemia or of continued fever, so close sometimes is the re semblance. They are partly constitutional, owing to admixture with the blood of decaying atoms of organic matter from the disintegrating valve ; partly local, from embolisms which interfere with the function of special organs. Thus there is high fever with marked remissions ; great weak ness and prostration ; a furred dry tongue ; often sickness, and perhaps diarrham, thirst, and anorexia. The pulse is small, rapid, and weak ; the breathing hurried ; and the child gradually becomes restless and deli rious, or drowsy and comatose. The local symptoms are derived from the organ or organs, whose function is interfered with by arrest of emboli in their minute arteries or capillaries. Thus, embolisms in the skin produce petechike from minute extravasations ; in the liver, swelling and perhaps jaundice ; in the kidney, albumen and blood in the water ; in the spleen, swelling and tenderness ; in the brain, paralysis ; or if from small dissemin ated emboli, headache, delirium, and coma, without special interference with motor function. In all these cases examination of the heart reveals the signs of valvular disease. The cases generally end fatally.
The pleura is often affected in rheumatism, alone or in conjunction with the pericardium. Pleurisy and pericarditis may occur simultaneously, or the inflammation may spread from one membrane to the other. When the two diseases are present together, the inflammatory processes in the two situations may be perfectly independent the one of the other. The ef fusion in the pleura may be purulent, and that in the pericardium serous ; or the pericardium may contain pus, and the pleura pure serum.
A little boy, aged six years, died in the East London Children's Hos pital of pleurisy and pericarditis. On examination the right lung was found adherent to the pericardium, and partially to the chest wall. It was condensed and tough from pressure, and the pleura of that side contained a large quantity of clear fluid. The pericardium was adherent to the heart in places, and iu the sac were about two ounces of thick pus. In this case the illness had begun with sickness and pain in the side, followed by cough —symptoms which pointed to pleurisy ; and three weeks afterwards, when the child first came under observation, there was slight but distinct con traction of the right side, shown by lowering of the shoulder and angle of the scapula, with distinct curving of the spine—the convexity to the left. These signs, taken in conjunction with the history, seemed to indi
cate that the pleurisy had dated from the beginning of the illness, and that therefore, if it did not give rise to the pericarditis, was not, at any rate, secondary to it.
Pneumonia is not rare in rheumatic fever, and may occur in conjunc tion with pleurisy or independently of it. A much rarer lesion is menin gitis affecting the membranes at the convexity of the brain and those of the spine. These cases are characterised by high fever, headache, and de lirium. Still, we must not suppose that in every instance where such symptoms occur iu the course of acute rheumatism they are due to inflam mation of the cerebral meninges. Many cases are now on record in which these symptoms have been present, with others—all pointing to the head as the seat of the lesion, and yet on dissection of the dead body no signs of disease have been discovered within the cranium. Dr. Latham has described a case of this kind which occurred in a little scholar at Christ's Hospital. The boy had high fever, headache, delirium, and convulsions ; and died in spite of energetic treatment directed against a supposed men ingitis. Examination of the body disclosed no disease of the brain or its membranes ; instead, there were all the signs of a severe pericarditis—a disease which had not been so much as suspected during life. Trous seau believed this form of " cerebral rheumatism," which leaves no trace of intracranial inflammation behind it, to be a neurosis depending upon some such mysterious modification of nerve-substance as is believed to oc cur in hysteria and tetanus. The symptoms may, however, be explained more simply by attributing them merely to the effects of hyperpyrexia ; and this is the view commonly accepted in the present day. SuCh a case has never come under my observation ; nor have I ever seen a case of rheumatic iritis in the child, nor of peritonitis occurring in the course of acute rheumatism.
Peritonitis may, however, be simulated by rheumatism of the abdomi nal muscles which sometimes occurs in children. If this be severe, there is tenderness on pressure of the abdominal wall, the child may have an appearance of great distress, and may lie in bed with his knees flexed on his abdomen, as if he were really suffering from inflammation of the peri toneum. The bowels are usually confined. These cases may be readily distinguished by careful examination. The face, although Often distressed, has not the haggard look which is so characteristic of peritonitis ; there is little or no tension of the abdominal wall ; the natural markings are not lost ; the tenderness is not extreme ; the pulse is soft, compressible, and of moderate quickness, not rapid and hard ; and the temperature is normal or only slightly elevated. There is generally great acidity of urine ; it is scanty and high-coloured, and its passage may cause some scalding.