ACUTE ARTICULAR RHEUMATISM. 



531 



speaking of heart-diseases, we fully showed that the frequency of these 

 complications has been greatly exaggerated, particularly by JEtouillaud. 

 Apparently, Bouillaud considered inflammation as the cause of the 

 above-mentioned " blood-murmurs," which are probably due to an abnor- 

 mal tension and consequent irregular vibration of the valves and walls 

 of the vessels. We have mentioned that, according to Bamberger > & 

 statistics, the complication with endocarditis occurs in about twenty 

 per cent., with pericarditis in about fourteen per cent., of the cases of 

 acute articular rheumatism, while myocarditis is much rarer. Accord- 

 ing to Bamberger's observation, the tendency to complicating inflam- 

 mation of the heart and pericardium is greater in proportion to the 

 number of joints affected. In these cases the heart-affection is a com- 

 plication and not a metastasis, as is shown by the fact that, when any 

 form of carditis develops, the affection of the joint continues as it was 

 previously. For the symptoms and course of the heart-affection, we 

 will also refer to what has been said, and shall only again call atten- 

 tion to the fact that, in many cases, there are no subjective symptoms, 

 and the complication is only recognized by physical examination 

 Pleurisy and pneumonia are far rarer complications than the different 

 forms of carditis, and still rarer ones are cerebral and spinal menin- 

 gitis. In protracted cases, suppuration of the joints may lead to pyae- 

 mia ; but, as this termination of idiopathic arthritis is rare, such cases 

 are very uncommon. 



The disease has no cyclical course, and lasts, with varying inten- 

 sity, in mild cases, one or two weeks ; in severe ones, for many weeks. 

 The pain and fever usually remit in the morning, and exacerbate in 

 the evening ; but these variations are not regular. Frequently, cases, 

 which at first appeared mild and favorable, subsequently become very 

 obstinate and malignant ; and, in the midst of an apparent improve- 

 ment, which has given hopes of a speedy recovery, the fever and local 

 symptoms suddenly become worse again, and advance to a height not 

 previously attained, 



In regard to the results of acuto articular rheumatism, we must 

 especially bear in mind that not only the mild cases, where few joints 

 are affected and the fever is slight, may recover completely, but that 

 recovery is also the usual termination for severe cases, where numerous 

 joints are inflamed, very painful, and much swollen, and where the 

 severe local symptoms are accompanied by corresponding fever. But, 

 even in favorable cases, recovery does not take place with sudden sub- 

 sidence of the symptoms, but with then* gradual and not always regular 

 diminution. Notwithstanding its treacherous course and its frequent 

 complication with inflammation of the most important organs, this 

 malady rarely terminates fatally. Death seldom occurs, except when 



