532 DISEASES OF THE ORGANS OF LOCOMOTION. 



the cardiac complications are unusually severe and are accompanied by 

 inflammation of the lungs and pleura ; even in such cases, recovery often 

 takes place, contrary to all expectation. Occasionally, also, death oc- 

 curs with the symptoms of sudden collapse, when there is no complica- 

 tion, being preceded for a short time by delirium, coma, or other symp- 

 toms of great nervous disturbance. On autopsy, in such cases, no 

 changes can generally be found in the central organs of the nervous 

 system ; hence it has been supposed that they depend on an unex- 

 plained blood-poisoning. But it seems to me that this hypothesis is 

 unjustifiable, till careful observations of the bodily temperature have 

 shown that, in these cases, the fatal result is not due to the fever and 

 the increase of the temperature to a point fatal to life ; particularly 

 since it has been shown that, in this disease, the temperature, which is 

 usually moderate, may rise quite high. In a few instances, moreover, 

 the severe brain-symptoms depend on inflammation of the meninges, 

 that is, on changes analogous to those in the joints. I myself have only 

 seen one case where the moderate increase of bodily temperature, the 

 delirium in the first stage, and the subsequent coma, together with ex- 

 cessive retardation of the pulse and repeated vomiting, left no doubt 

 as to the nature of the disease. This case ended in recovery, so that 

 the diagnosis was not confirmed by autopsy ; but in a dissertation 

 written by Dr. Flamm, under the direction of my colleague Kbhler, 

 on " Meningeal Symptoms in Acute Rheumatism," cases are reported 

 where post-mortem, examination showed the presence of inflammatory 

 disease of the meninges. It has not yet been decided whether the 

 chronic cerebral disturbances, occasionally left after acute articular 

 rheumatism are due to perceptible anatomical changes. G-riesinget 

 speaks of them as follows : " The severe cerebral disturbance, lasting 

 for months or more, caused by articular rheumatism, appears as insan- 

 ity without fever, characterized by depression, or as pronounced melan- 

 choly with stupor. It may be followed, or may alternate, with states 

 of excitement ; sometimes this disturbance is accompanied by convul- 

 sive choreic movements ; the prognosis is, on the whole, favorable ; 

 recovery seems to result most rapidly and certainly where, after a time, 

 during the cerebral disturbance, the joints are again attacked with 

 acute rheumatism." Acute articular rheumatism very often ends in 

 incomplete cure. In many cases the fever, severe pain, and the swell- 

 ing of most of the joints disappear, but a chronic rheumatism remains 

 in certain joints, proves very obstinate, and often never entirely disap- 

 pears. Still more frequently the patients live through the acute artic- 

 ular rheumatism and its complications, but acquire valvular disease of 

 the heart, which is never cured, and of which they soon die. After 

 the disease has lasted a long time, particularlv if the fever was severe, 



