RHEUMATIC FEVER, OR ACUTE RHEUMATISM. 471 



extends to the pericardium, or bag or membrane which encloses the heart, 

 giving rise to the disease which we call "pericarditis." This inflammation may 

 result in the formation of a quantity of fluid in the pericardium surrounding the 

 heart, and then we have a condition of "pericardial effusion." Frequently the in- 

 flammation attacks the endocardium, or membrane lining the heart, and then we 

 have what is called " endocarditis." Sometimes the substance of the heart itself is 

 attacked, and then we have that condition which we speak of as " myocarditis." 

 In fact, in nearly all cases in which there is pericarditis or endocarditis there is 

 more or less myocarditis. The occurrence of these complications is a matter of very 

 serious moment to the patient. Sometimes they set in with pain and tightness in 

 the chest, but they may come on quite insidiously, and without anything to attract 

 attention to what is going on. The medical man can always detect their existence 

 by carefully listening over the region of the heart, and it is for this reason that he 

 is always so particular to examine the chest with his stethoscope every day. Were 

 he not to take this precaution he would have very little real knowledge of the 

 progress of the case. 



Pleurisy sometimes occurs as a complication of rheumatic fever, but far less com- 

 monly than heart disease. 



The inflammation in rheumatic fever is seldom confined to one joint, but shifts 

 about in the most erratic manner. This morning, for example, the pain may be 

 confined to the right knee, a few hours later it may have entirely subsided, whilst 

 before night it may re-appear in the corresponding joint on the opposite side, or 

 perhaps in the ankles or wrists. This " metastasis," as it is called, is always a 

 marked feature of acute rheumatism. In the majority of cases in the first attacks 

 only the larger joints of the body are affected. 



The pain in the joints is generally very severe, but less intense than in gout. A 

 humorous Frenchman, endeavouring to convey his idea of the relative pains of gout 

 and rheumatism, once said, " Place your joint in a vice, and screw the vice up until 

 you can endure it no longer. That may represent rheumatism. Then give the 

 instrument another twist, and you will obtain a notion of gout." 



The temperature of the body, as estimated by the thermometer, is usually 

 elevated by some three or four degrees. The rapidity of the pulse is in acute rheu- 

 matism no guide to the amount of fever, as the existence of heart disease as a 

 complication would tend to influence its rate. To arrive at a knowledge of the 

 amount and severity of the fever it is absolutely necessary to employ the 

 thermometer. 



The smell of the perspiration in this complaint is very characteristic, and will 

 often enable the practised observer to make a shrewd guess as to the nature of the 

 illness from which the patient is suffering before asking a single question. 



A person who has once suffered from rheumatic fever is very likely to suffer from 

 it again. The occurrence of one attack imparts a great susceptibility to the system 

 for its return, and this is increased with every successive attack, so that after a time 

 the patient is liable to become the victim of frequent seizures. It very commonly 

 iiappens that the second and third attacks are less severe than the first. 



Sometimes the disease assumes a sub-acute form, intermediate in its characters 



