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HARVEIAN LECTURES 
 
 1888 
 
BY THE SAME AUTHOR. 
 
 Crown 8vo. 5$. 
 
 ON THE PRINCIPLES AND EXACT CONDITIONS 
 
 TO BE OBSERVED IN THE ARTIFICIAL FEEDING OF 
 INFANTS : THE PROPERTIES OF ARTIFICIAL FOODS : 
 AND THE DISEASES WHICH ARISE FROM FAULTS OF 
 DDZT IN EARLY LIFE. A Series of Lectures delivered in 
 the Post Graduate Course at St. Mary's Hospital, and at the 
 Hospital for Sick Children, Great Ormond Street, 1887. 
 
 London : SMITH, ELDER, & CO., 15 Waterloo Place. 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/variousmanifestaOOchea 
 
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THE VARIOUS MANIFESTATIONS 
 
 OF THE 
 
 EHEUMATIC STATE 
 
 AS EXEMPLIFIED IN 
 
 CHILDHOOD AND EAELY LIFE 
 
 LECTURES DELIVERED BEFORE 
 
 THE HARVEIAN SOCIETY OF LONDON 
 
 BY 
 
 W. B. CHEADLE, M.D. 
 
 PHYSICIAN TO ST MARY'S HOSPITAL, AND LECTURER ON MEDICINE ST MARY'S 
 
 MEDICAL SCHOOL ; SENIOR PHYSICIAN TO THE HOSPITAL FOR 
 
 SICK CHILDREN, GREAT ORMOND STREET 
 
 LONDON 
 SMITH, ELDER; & CO., 15 WATERLOO PLACE 
 
 1889 
 
 {All rights reserved] 
 
PREFACE 
 
 These Lectures were originally published in the 
 Lancet; and I have to express my thanks to the 
 proprietors of that journal for their courtesy in 
 permitting their early reproduction in the present 
 form. 
 
 W. B. C. 
 
 19 Portman Street, W. 
 June 15, 1889. 
 
viil CONTENTS 
 
 LECTURE III, 
 
 PAGK 
 
 Pericarditis — Its connection with other phases of rheumatism — 
 Special characteristics in childhood — Subacute, recurrent, 
 dry — Tendency to fibrosis and chronic thickening rather than 
 to effusion — Endocarditis ; subacute and recurrent likewise — 
 Special liability of children and of young girls — Connection 
 of endocarditis with other phases of rheumatism — The 
 endocarditis of chorea — Relation of pericarditis and endo- 
 carditis to the evolution of nodules — Morbid changes in 
 nodules and cardiac valves analogous — Significance of this 
 — Different forms of valvular disease — Mitral stenosis — 
 Early signs — Double second sound at the apex — Hypertrophy 
 and dilatation — Comparative rarity of dropsy — The mode 
 of death differs from that met with in adults — Scarlatinal 
 rheumatism — Rheumatoid arthritis — Special points in treat- 
 ment . . . , 79 
 
THE VARIOUS MANIFESTATIONS OE THE 
 
 RHEUMATIC STATE 
 
 AS EXEMPLIFIED IN 
 
 CHILDHOOD AND EARLY LIFE 
 
 BEING THE HARVEIAN LECTURES FOR 1.888: 
 
 LECTUEE I. 
 
 Rheumatism not to be regarded as a mere affection of the joints — 
 Arthritis only one of many rheumatic phenomena — Various 
 phases of the rheumatic state — General characteristics of the 
 rheumatism of childhood as compared with that of adults— Com- 
 parative insignificance of the joint affection — Greater prominence 
 and frequency of other phases — Tendency of the various phe- 
 nomena of the rheumatic series to appear independently — They 
 may occur singly, or in various combinations, in varying order of 
 sequence, at different intervals of time — Examples — Influence of 
 sex — Influence of inherited tendency — The rheumatic phenomena 
 considered in detail — Arthritis — Special characters in childhood 
 — Variation in the chief symptoms from the adult type. 
 
 There is perhaps no serious disease more familiar 
 to us than .acute articular rheumatism; it is one of 
 the disorders most commonly seen in the Wards of 
 a general hospital ; it is constantly encountered in 
 
 B 
 
2 ACUTE RHEUMATISM 
 
 private practice; and I must confess" that -when I 
 chose Rheumatism as the subject of the Lectures 
 which you have done me the honour to ask me to 
 deliver, I was almost afraid that it might be deemed 
 too trite and commonplace, destitute of sufficient 
 novelty and interest. But there is a certain advan- 
 tage in treating of a matter with which the audience 
 are familiar, and I trust I shall be able to present 
 it to you in some new aspects, and to attract 
 attention to certain points of great interest, hitherto, 
 I think, insufficiently considered ; and thus I hope 
 that my choice may be justified, and any unfavourable 
 criticism in this respect eventually disarmed. 
 
 I must premise, at the outset, that in these 
 Lectures I shall use the terms 'rheumatism' and 
 ' rheumatic ' in the strictest sense, as applying only to 
 that form which is distinguished as acute or genuine 
 rheumatism, of which what is known as rheumatic 
 fever is the most extreme expression in adults, but 
 which appears with every degree of acuteness and 
 severity, and also, as I hope to show, in many 
 different phases. 
 
 Acute articular rheumatism is not only an 
 extremely common disease, but it has very striking 
 and obvious symptoms by which it is readily recog- 
 nised ; the swollen, tender, painful joints, the fever, 
 
ARTHEITIS ONE PHASE ONLY 3 
 
 the profuse sour-smelling perspirations, render a 
 typical case unmistakable and distinct ; yet this is a 
 picture of the disease very rarely seen in childhood. 
 Even in its milder forms, genuine articular rheu- 
 matism preserves its special features ; some may be 
 absent, others modified ; yet the stiffness, tenderness, 
 and swelling of joints usually indicate the nature of 
 the affection. But this, again, does not represents, 
 rheumatism completely as seen in childhood. We 
 are so accustomed to associate the term ' rheumatism ' 
 with this condition of the joints, to regard arthritis 
 as the chief and essential feature, and any associated 
 affections of other parts as mere complications, that 
 it is difficult at first to realise that articular inflam- 
 mation is only one of many direct and sometimes 
 independent manifestations of the rheumatic state. 
 This is, however, the one central idea which I wish 
 to enforce. The ordinary conception of acute rheu- 
 matism, as essentially characterised by articular in- 
 flammation, is based upon observation of the disease 
 as we see it in adults ; in them the arthritis is one 
 of the most constant, prominent, and characteristic 
 of the morbid phenomena which arise. The names 
 rheumarthritis, polyarthritis, polyarthritis synovialis, 
 and polyarthritis rheumatica acuta, reflect this narrow 
 view. 
 
 B 2 
 
4 THE RHEUMATISM OF CHILDHOOD 
 
 A study of the disease in children, however, leads 
 to a far wider conception. In the rheumatism of 
 early life other morbid conditions appear prominently 
 and constantly, which may claim, equally with the ar- 
 thritis, to be regarded as direct results of rheumatic 
 activity ; in childhood arthritis cannot be regarded 
 as alone typical, essential, and representative. 
 
 The most complete and comprehensive manifest- 
 ation of the various phases of rheumatism belongs, 
 indeed, to the period of childhood ; it appears then, 
 under the simplest condition ; this presentation of 
 the disease should be regarded as representative, 
 and the changes which take place in the phenomena 
 with advancing age regarded as modifications of the 
 earlier and more perfect form. I will ask you, 
 gentlemen, to put aside, at any rate for the moment, 
 this limited and narrow view of rheumatism as in- 
 separably associated with arthritis, a view based 
 upon observation of the disease in grown persons, 
 and to look at it from a new standpoint. 
 
 There are certain affections which have been 
 observed to be so frequently associated with acute 
 rheumatism that the existence of some pathological 
 connection between them has come to be very gene- 
 rally accepted, although the extent and intimacy 
 of the association may be a matter of controversy. 
 
CONTRASTED WITH THAT OF ADULT LIFE 5 
 
 Endocarditis and pericarditis, for example, are so 
 constantly seen as immediate accompaniments of 
 articular rheumatism, even in adults, that there is 
 no question of their relation to it ; and in the case 
 of children the connection is still more frequent and 
 more intimate. Pleurisy, again, and tonsillitis are 
 allowed to be not unfrequently accompaniments of 
 articular rheumatism in both periods of life. But 
 with these I think the list ends as far as adults are 
 concerned. If we turn to children, however, we learn 
 that the scope of acute rheumatism is wider still. 
 Other manifestations appear in undoubted associa- 
 tion with it in early life, and must be included in 
 the series of rheumatic phases, although some decline 
 or disappear in later life. Subcutaneous tendinous 
 nodules, chorea, and exudative erythema are (the 
 first I think always, the two latter commonly) deve- 
 lopments of rheumatism. There are other affections 
 which have been deemed by some to be minor expres- 
 sions of the rheumatic diathesis. I have not satisfied 
 myself upon this point, and I wish to limit the list 
 to those generally accepted as having some connec- 
 tion with it. The claims of endocarditis, of pericar- 
 ditis, of pleurisy, of tonsillitis, of exudative erythema, 
 of chorea, of subcutaneous nodules, will hardly, I 
 think, be seriously disputed. I shall have something 
 
6 VARIOUS PHASES OF THE EHEUMATIC STATE 
 
 to say on this point when I come to speak of them in 
 detail ; bnt for my present purpose I shall assume 
 the connection and speak of these seven phases, to- 
 gether with arthritis, as the rheumatic series. 
 
 Let me not be misunderstood in this matter 
 however. I do not say that the rheumatic poison, 
 or whatever the morbid influence may be, is the sdle 
 cause of these affections associated with rheumatic 
 arthritis, any more than it is the sole cause of inflam- 
 mation of joint structures. They are set up by other 
 causes, just as arthritis, for example, may be set up by 
 mechanical injury, by the poison of gout, or that of 
 septicemia or pyaemia. Yet the rheumatic poison is 
 the most common exciting cause of arthritis, and so 
 with other members of the rheumatic series. Take, 
 for instance, pericarditis, endocarditis, and pleurisy. 
 The most common cause of the first two, at any rate, 
 is rheumatism. Yet these same inflammations of 
 the pericardium, endocardium, and pleura are now 
 and again set up by the septic or pysemic poison, or 
 that of uraemia. Tonsillitis, erythema, and chorea in 
 like manner are undoubtedly set up by other exciting 
 causes as well as by rheumatism, although the latter 
 is a frequent and potent one. The only manifestation 
 of the series absolutely and solely rheumatic, never 
 stirred up, as far as I know, by any stimulus except 
 
BROAD CONCEPTION OF RHEUMATISM 7 
 
 the rheumatic stimulus, is the evolution of sub- 
 cutaneous tendinous nodules. 
 
 It appears, then, that the rheumatic virus (what- 
 ever its exact nature and by whatever physiological 
 machinery it acts) which produces the articular inflam- 
 mation produces in like manner inflammation of the 
 fibrous tissue of the pericardium, endocardium, and 
 pleura, and that of fasciae and tendons. It has clearly 
 an irritant inflammatory effect upon fibrous tissue, 
 not of the joints alone but of these other structures. 
 It affects, moreover, mucous membrane and skin, and 
 disturbs nervous centres. The conception of rheu- 
 matism, then, which I shall endeavour to put for- 
 ward and establish is this broad one ; that the terms 
 6 rheumatism ' and ' rheumatic ' must be held to in- 
 clude many various morbid expressions — the series 
 of phenomena I have laid down — and must not be 
 regarded as a special inflammation of tendons and 
 ligaments or synovial membranes, or as a condition of 
 which this is always the chief feature, accompanied 
 by complications and sequelse. The term ' diathesis ' 
 is quite inadequate ; there is something more than 
 mere tendency — a common factor concerned in the 
 production of those different phases — and forming 
 the link between. 
 
 The rheumatism of childhood exhibits a marked 
 
8 THE RHEUMATISM OF CHILDHOOD 
 
 contrast to the disease as it is seen in mature life. The 
 articular affection, which is regarded as the very type 
 and essence of the latter, has not yet become the 
 chief feature, but is usually slight and subordinate, 
 and, indeed, may be absent altogether from a seizure 
 undoubtedly rheumatic in its nature; while other 
 phases, again, less marked in the disease of adult life, 
 or even absent from it altogether, rule as prominent 
 and characteristic features. The joint tissues are less 
 susceptible ; the other fibrous tissues more so. Subcu- 
 taneous nodules, which are so frequent and significant 
 in early life, practically disappear with the advent 
 of puberty ; and chorea, so common in connection 
 with the rheumatism of childhood, disappears as full 
 maturity is reached. Endocarditis and pericarditis, 
 again, frequent as they are in adult life, are more 
 frequent still in children — i.e. they tend to decline 
 as age advances. 1 In the rheumatism of early life 
 arthritis is at its minimum; endocarditis, pericarditis, 
 chorea, and subcutaneous nodules at their maximum. 
 As life advances this is gradually reversed ; the joint 
 
 1 The statistics of the Collective Investigation Committee of the 
 British Medical Association {British Medical Journal, Feb. 1888) 
 give 72 per cent, of heart-disease in rheumatism in the case of chil- 
 dren, as compared with 46 per cent, in male adults. In the case of 
 female adults the difference is not so marked— i.e. they retain in 
 some degree the special proclivity of childhood. 
 
REPRESENTATIVE OF THE DISEASE 9 
 
 affection becomes more prominent, constant, and typi- 
 cal of the disease, and reaches its maximum; while 
 the other phenomena decline and tend to die out. So 
 that, if the picture of the disease had been drawn 
 originally (as it should be) from the rheumatism of 
 childhood, the articular affection would not have been 
 taken as representative, or endocarditis and pericar- 
 ditis spoken of as complications. Endocarditis or 
 chorea would have been taken as the primary essen- 
 tial phenomena, and the articular affection as a 
 complication. Yet none are really to be regarded 
 as complications.. When, for instance, any of these 
 phases — pericarditis, nodules, or chorea — occur in- 
 immediate association with arthritis, they are in no 
 way set up by the arthritis ; they may come before 
 it or after it, or occur quite independently. And so 
 with the articular affection : the various phases are 
 not complications or sequelse, but direct manifesta- 
 tions of rheumatic activity. 
 
 Another point of distinction between the rheu- 
 matism of childhood and that of later life is the ten- 
 dency of the various phases to arise independently 
 and apart from each other. ' They do, indeed, occur 
 grouped together commonly enough, as in adult life; 
 but often also the series of rheumatic events is spread 
 out, scattered over a period of months or years, so 
 
10 THE SERIES OF RHEUMATIC EVENTS 
 
 that tlie history of a rheumatism may be the history 
 of childhood. There may be, for instance, an endo- 
 carditis at one time, a chorea at another, a tonsil- 
 litis at another, without any other manifestation at 
 the moment, and yet each may be as essentially an 
 expression of rheumatism as the articular affection 
 which may perhaps have happened long before or 
 does not appear until long after. Look, for instance, 
 at Series YIIL, in the abstracts of cases in the table, 
 showing the succession of rheumatic events — the first 
 event was chorea, the articular affection not occurring 
 until eleven months later ; or at Series II., where 
 the first event was an endocarditis which had occurred 
 years at least before any arthritis was observed ; or 
 at Series X., where there were two attacks of chorea 
 before the arthritis appeared. There was nothing, 
 under the present system of taking articular affection 
 as the key to the condition, to show that the chorea 
 or endocarditis were rheumatic at the time they oc- 
 curred. More usually, however, two or three phases 
 occur more or less closely together ; as, for instance, 
 the common coincidence of arthritis with endocarditis 
 (as in Series I.), or chorea, nodules, and endocarditis. 
 The rheumatic series as seen in children may, 
 indeed, be complete or incomplete in any degree. 
 The whole series may follow in succession or it may 
 
VARYING ORDER OF SUCCESSION 11 
 
 be limited to a single event — even an arthritis only, 
 or a chorea only, or an endocarditis only, without 
 subsequent development of any other rheumatic 
 seizure. Again, the combinations of the different 
 phases of the rheumatic series may follow any 
 order of sequence. Sometimes — most commonly — 
 an arthritis first; sometimes a chorea first, or an 
 endocarditis. We are so accustomed to regard 
 arthritis as the starting-point, and other manifesta- 
 tions as complications or sequelse, that the possibly 
 rheumatic nature of the affections which come before 
 it is liable to be overlooked. Yet these manifesta- 
 tions, developed previously to arthritis, cannot be 
 looked upon as complications or sequelse, for there is 
 no arthritis to complicate or follow. They are direct 
 and independent results of the rheumatic disturbance. 
 Further, these phases of the rheumatic series may be 
 either closely associated in point of time, singly or in 
 groups, or scattered, with varying intervals between. 
 Here, again, we are so accustomed to look at the 
 short series of adult rheumatism, minus chorea and 
 nodules, occurring in conjunction with arthritis, that 
 even a group of significant affections occurring apart 
 from arthritis would hardly be recognised as rheu- 
 matic. And so on with the other members of the 
 morbid series, some of which, again, may be repeated 
 
12 CLINICAL EXAMPLES 
 
 more than once. Clinical examples, from cases ac- 
 tually observed, will serve to illustrate most clearly 
 some of the various combinations and the wide range 
 and protean character of rheumatism in children. 
 The most frequent of all is the one with which we 
 are so familiar in adults. 
 
 Series I — (1) Arthritis ; (2) endocarditis; these 
 may recur more than once without other phases- H. 
 
 B. K , a boy of nine, was brought to the Hospital 
 
 for Sick Children in January 1888, with rheumatism 
 of the joints and advanced mitral disease. Here the 
 arthritis recurred almost yearly, and probably the 
 endocarditis also, for when examined in 1888 there 
 were marked thrill, a double murmur at the apex, 
 and enormous hypertrophy and dilatation ; while the 
 chorea did not appear until six years after the first 
 arthritis. Often in childhood to these two manifes- 
 tations are added the development of nodules, and 
 perhaps pericarditis or pleurisy. 
 
 Series II. — C. H. B was brought to the 
 
 Hospital for Sick Children in May, 1888, for pains in 
 the knees and in various joints. Small subcutaneous 
 nodules were found on the knees, elbows, and 
 malleoli. He had had pains in the back of the knees 
 and in the ankles for the previous five weeks, never 
 before. There was a double mitral murmur with 
 
COMBINATIONS OF THE DIFFERENT SERIES 33 
 
 great hypertrophy. Pleurisy developed on June 7th ; 
 then a fresh crop of nodules on June 9th; peri- 
 carditis on June 11th, and again on July 14th; a 
 fresh crop of nodules on July 14th. With this came 
 excited action of the heart ; the pulse rose to 140, 
 marking the advent of fresh endocarditis and pro- 
 bably of pericarditis. Pleurisy (slight) followed on 
 August 16th; after this, gradual failure, and death 
 on September 6th. In this case the primary endo- 
 carditis must have occurred some years before the 
 pains in the joints were first noted, which was only 
 five weeks before admission, whereas the heart-disease 
 was of long standing, as evidenced by the great hyper- 
 trophy. It is to be noted, too, in this case how 
 endocarditis, pericarditis, and pleurisy coincided with 
 the appearance of fresh crops of nodules. 
 
 Another common combination is that repre- 
 sented in 
 
 Series III. — (1) Arthritis and endocarditis ; (2) 
 
 chorea. George S , aged seven years and a-half, 
 
 was admitted for right paretic hemichorea. He had 
 had rheumatic arthritis seven months before, accom- 
 panied by endocarditis, evidenced by a loud mitral 
 murmur. Two months later he had chorea ; then a 
 second attack, for which he was admitted. There 
 was a family history of rheumatism; the father had 
 had rheumatic fever ; the mother chorea as a child. 
 
Clinical Examples of Different Combinations 
 
 Series I. 
 
 - : 
 
 Series III. 
 
 Series IY. 
 
 Series Y. 
 
 H. B. E. C. H. B.. boy aged G. S., aged seven. 
 
 nine. (Hosp. Sick ! five. I Hosp. Sick (Hospital Sick 
 
 Children, 1888.j Children, 1888.) Children.) 
 
 ( A PTTTPTTT^ 
 
 1. - ENDOCARDITIS. 1. Endocarditis (?; 1. 
 ( (1882.) 
 
 ( Arthritis. 
 \ endocarditis. 
 ( (1884.) 
 
 I Arthritis, 
 
 | ENDOCARDITIS 
 
 ' . Pte- 
 1 curring almost 
 
 yearly for 
 I '6 years.; 
 
 J 
 
 Arthritis, 
 endocarditis. 
 I (18 
 
 Arthritis. 
 endocarditis. 
 
 (1857.; 
 
 ( Arthritis, 
 ( (1888.) 
 
 2. i 
 
 Arthritis, 
 
 evolution of 
 
 NODULES. 
 
 (March, 1888.) 
 
 Second crop 
 
 Of NODULES, 
 
 PLEURISY, 
 
 PERICARDITLS. 
 
 (June, 1888.) 
 
 Third crop 
 
 Of NODtTLES, 
 
 fresh 
 
 ENDOCARDITIS, 
 
 fresh 
 
 ::DITIS. 
 
 (July, 1888.; 
 
 / Pleurisy, 
 
 u akditis 
 1 (recurrent). 
 
 U August, 1888.) 
 
 Arthritis, 
 
 ENDOCARDITIS. 
 
 ( Chorea fire 
 \ months later. 
 
 Chorea after 
 two months' 
 
 interval. 
 (Father had 
 rheumatic 
 fever ; mother 
 had chorea 
 as a child.) 
 
 H. C, aged ten. 
 (Hospital Sick 
 Children, 1878.) 
 
 ( Chorea, 
 
 1. j endocarditis 
 
 ( (1875.) 
 
 ( Mitral 
 - disease found. 
 ( (1878.) 
 
 Arthritis 
 absent. 
 (Mother 
 rheumatic 
 fever and 
 heart disease.) 
 
 A. \Y, aged 
 sixteen. (St. 
 Mary's Hosp.) 
 
 I Chorea, 
 , J endocar- 
 
 j DITIS. 
 
 { (1874.) 
 
 Mitral disease 
 found with — 
 
 Arthritis 
 
 four years 
 
 later 
 
 (1878.) 
 
OF VARIOUS PHASES OF THE RHEUMATIC SERIES. 
 
 Series VI. 
 
 A.B., aged twelve. 
 
 (St. Mary's Hosp., 
 
 1834.) 
 
 Arthritis, 
 
 ENDO CAR- 
 DITIS. 
 
 (1881.) 
 
 Chorea. 
 (Dec. 1884.) 
 Old- 
 standing 
 
 MITRAL 
 DISEASE 
 
 discovered. 
 
 Series VII. 
 
 F. M. C, aged 
 seven. 
 
 Arthritis 
 
 (severe), 
 
 tonsillitis. 
 
 (1878.) 
 
 t Purpura 
 ] rheumatica. 
 ( (1883.; 
 
 Peri- 
 carditis. 
 (Jan. 1885.) 
 
 Chorea 
 
 (1883.) 
 
 f Tonsillitis, 
 
 constantly 
 4. -I recurring for 
 several years. 
 { (1883-4-5.) 
 
 Series VIII. 
 
 5. J 
 
 Series IX. 
 
 W. S., aged four 
 
 years and a-half. 
 
 (Hosp. Sick Ch., 
 
 1887.) 
 
 Chorea 
 probably ac- 
 companied by 
 ENDOCARDITIS. 
 (Nov. 1886.) 
 
 Interval of eleven 
 months. 
 
 ( Arthritis, 
 
 2. -\ first attack. 
 
 ( (Oct. 1887.) 
 
 {Chorea 
 (second attack), 
 SUBCUTANEOUS 
 NODULES, 
 ENDOCARDITIS, 
 ERYTHEMA 
 MARGINATUM 
 (NOV. 1887.) 
 
 Emotional 
 attacks, 
 
 CHOREA 
 
 (continued), 
 
 FRESH 
 NODULES. 
 
 (Dec. 1887.) 
 
 Erythema 
 marginatum, 
 fresh eruption 
 
 Of NODULES, 
 CHOREA 
 
 (relapse), 
 
 arthritis 
 
 (second attack), 
 
 (Jan. 1888.) 
 
 / Fresh eruption 
 of erythema, 
 R J fresh crop of 
 
 b * "j NODULES, 
 
 TONSILLITIS. 
 
 I (Feb. 1888.) 
 Death, March 1888 
 
 F. M., aged five 
 (Hosp. Sick Ch., 
 
 Arthritis. 
 
 (Sept. 1887.) 
 
 Us 
 
 Series X. 
 
 John T., aged seven. 
 
 (Hosp. Sick Children, 
 
 Dec. 1887.) 
 
 ■ 
 
 Chorea, 
 attributed to 
 
 fright. 
 (Nov.l886.) 
 
 Arthritis 
 (second attack.) 
 [ (Jan. 1888.) 
 
 Chorea, 
 
 eruption of 
 
 nodules, 
 
 endocarditis 
 
 (first attack). 
 
 (March, 1888.) 
 
 Arthritis 
 
 (third attack). 
 
 (April.) 
 
 Erythema 
 
 marginatum. 
 
 Chorea 
 
 (second attack), 
 
 eruption of 
 
 NODULES 
 
 (second attack). 
 L (Dec. 1883.) 
 
 Chorea 
 (second attack), 
 likewise attri- 
 buted to fright. 
 (Aug. 1887.) 
 
 Arthritis, 
 evolution of 
 
 NODULES. 
 
 (Nov. 1887.) 
 
 Endocarditis. 
 
 (Dec.) 
 
 Chorea 
 (third attack), 
 
 EMOTIONAL 
 
 ATTACKS, 
 
 LARGE NODULES 
 
 (second 
 eruption), 
 
 ARTHRITIS 
 
 (second attack), 
 
 ENDOCARDITIS, 
 
 PERICARDITIS, 
 
 PLEURISY. 
 
 I (June, 1888.) 
 
 f Endocarditis, 
 5. \ pericarditis. 
 [ (Julv, 1888.) 
 Death, Aug. 1888. 
 
16 CLINICAL EXAMPLES 
 
 Sometimes the arthritis appears to be missing. 
 Thus :— 
 
 Series IV. — Henry C , aged ten years and a- 
 
 half, was admitted to Great Ormond Street, June 
 1878, with mitral stenosis and regurgitation and 
 great hypertrophy. He had never had any joint 
 affection, but he had had chorea three years before. 
 It was found, moreover, that his mother had had 
 rheumatic fever, and was suffering from valvular 
 disease of the heart resulting from it. I think that 
 in this case the morbus cordis must be reasonably 
 attributed to rheumatic endocarditis ; the chorea to 
 rheumatic influence likewise, although no arthritis 
 had appeared up to the time of observation. 
 
 The combination in which the articular affection 
 appears last in the series throws much light on such 
 cases as the preceding. Here is an example : — 
 
 Series Y. — Alice W , aged sixteen, admitted 
 
 into St. Mary's Hospital complaining of pain, stiffness, 
 and tenderness of knees and ankles. On examining 
 the chest, well-marked mitral disease of old standing 
 was found — viz. a loud regurgitant murmur, with 
 great hypertrophy and dilatation. The original 
 endocarditis must have taken place years before. 
 Yet, observe, she was not known to have had any 
 joint affection before the present attack; but she 
 
COMBINATIONS OF THE RHEUMATIC SERIES 17 
 
 had had chorea four years before, and, moreover, her 
 mother had had rheumatic fever ; her mother's sister 
 had had rheumatic fever. Can there be any reason- 
 able doubt that both chorea and endocarditis (which, 
 no doubt, occurred with the chorea four years before 
 the articular rheumatism) were both of them rheu- 
 matic ? Yet, until the articular affection appeared, 
 which was delayed to the age of sixteen, this case 
 was exactly similar to the preceding. If the chorea 
 and accompanying endocarditis had been recorded at 
 the time of their occurrence, there would have been 
 nothing to stamp them as rheumatic, and the endo- 
 carditis would have been styled 6 choreic. 5 The 
 appearance of acute articular rheumatism afterwards, 
 and the family history of the disease in mother and 
 aunt, revealed the link between the different phases. 
 
 Another combination, where arthritis and endo- 
 carditis commence the series and pericarditis and 
 chorea follow later on, is thus shown : — 
 
 Series VI. — A. B , a girl of twelve, was 
 
 admitted into St. Mary's Hospital in 1884 for severe 
 chorea. She had had rheumatic fever three years 
 before ; she had also had endocarditis, as evidenced 
 by a loud mitral murmur. The chorea rapidly got 
 well under arsenic; but just at this point acute 
 pericarditis came on. There was not the slightest 
 
 c 
 
18 CLINICAL EXAMPLES 
 
 affection of the joints, yet I take it both chorea and 
 pericarditis were rheumatic. 
 
 You will observe that either endocarditis or peri- 
 carditis is present in each of the preceding series. 
 Yet these most serious of all the rheumatic phases, 
 present, as I have said, in nearly three-fourths of 
 articular affections in children, are sometimes want- 
 ing. Happily this was so in the case of one of my 
 own boys, and his history also illustrates the con- 
 nection of two of the less prominent phenomena 
 of the rheumatic series — viz. purpura rheumatica 
 and tonsillitis. 
 
 Series VII. — F. M. C , a boy of seven, had 
 
 acute articular rheumatism, with tonsillitis, in 1878. 
 There was no endocarditis or pericarditis or other 
 manifestation — arthritis and tonsillitis only ; and for 
 several years there was complete quiescence of rheu- 
 matic activity. Then in 188-3, or five years after the 
 arthritis, purpura rheumatica appeared; this was 
 unaccompanied by any other phase. Then, about 
 one year later, chorea and emotional attacks occurred. 
 Finally, he had tonsillitis, recurring frequently and 
 severely for four or five years. 
 
 In all the examples yet given the rheumatic series 
 has been incomplete, as indeed it is most commonly, 
 many of the minor phases especially being wanting. 
 
OF COMBINATIONS OF THE RHEUMATIC SERIES 19 
 
 This is, however, partly due no doubt to the imper- 
 fection of the record, many of the cases being taken 
 before the significance of subcutaneous nodules, 
 tonsillitis, and erythema was fully recognised. 
 
 I will add, therefore, in conclusion of this part of 
 the subject, three more combinations, in which the 
 series is fuller and almost complete. 
 
 Series VIII. — Look at the remarkable succession 
 of rheumatic events, occurring chiefly in groups, 
 
 given in this series. W. S , a boy of five, was 
 
 recently under my care in the Children's Hospital. 
 The first event was an attack of chorea in November, 
 1886, when the boy was between three and four 
 years old. This was almost certainly accompanied 
 by endocarditis, for a double mitral disease of old 
 standing was discovered on his admission to hospital 
 a year later. The second event was an attack of 
 articular rheumatism (the first), in October, 1887. 
 The third group of events was a second attack of 
 chorea, accompanied by an extraordinary develop- 
 ment of subcutaneous nodules, and also by fresh 
 endocarditis and erythema marginatum, in Novem- 
 ber, 1887. The fourth group of events was a series of 
 emotional attacks, accompanied by further evolution 
 of subcutaneous nodules and continued chorea, in 
 December, 1887. The fifth group of events comprised 
 
 c 2 
 
L>0 CLINICAL EXAMPLES 
 
 a second eruption of erythema, a second eruption 
 of subcutaneous nodules, a relapse of chorea, and 
 (last in order) a second attack of arthritis, in January, 
 1888. The sixth group of events consisted of a third 
 eruption of nodules, a third eruption of erythema, 
 and tonsillitis, in February, 1888, followed by death 
 in March. Here I would ask you to observe that the 
 very first event of the series was chorea (probably 
 accompanied by endocarditis), the first appearance of 
 rheumatism of the joints being delayed until one 
 year later ; so that, if we take the joint affection as 
 the test, there was nothing, when the chorea first 
 occurred, to indicate its rheumatic nature ; and it 
 would no doubt have been classed as non-rheumatic, 
 and the accompanying endocarditis simply termed 
 < choreic' The rheumatic relation was only estab- 
 lished by subsequent events, and the last phase was 
 tonsillitis, in an unusual place, late in the series. 
 
 Series IX. — The next example (F. M , aged 
 
 five, Hospital for Sick Children, 1886) is not quite 
 so complete, but represents a common sequence of 
 events. The first was articular rheumatism in 
 September, 1887. There was no other manifestation 
 at the time. The next event was a second attack 
 of articular rheumatism four months later (January, 
 : and this, again, was unaccompanied by any 
 
OF COMBINATIONS OF THE RHEUMATIC SERIES 21 
 
 other manifestation. The third event came three 
 months later still, when chorea developed, and this 
 was accompanied by an eruption of large subcutaneous 
 nodules, and with these the first sign of endocarditis, 
 and also another phase — erythema marginatum. The 
 fourth event, a month later still, consisted in a fresh 
 eruption of nodules only, followed by convalescence 
 and quiescence until December, 1888, when the boy 
 was readmitted to hospital with a fifth rheumatic 
 development, consisting of chorea and another erup- 
 tion of nodules. This case presents the unusual 
 feature of two attacks of arthritis without appreciable 
 endocarditis. A soft murmur was first found, without 
 hypertrophy, in the third period, together with the 
 chorea, an evolution of nodules, and a slight arthritis 
 of one wrist only. 
 
 Series X. — The last example which I have to give 
 exhibits the rheumatic events in different order. 
 
 J. T , a boy of seven, was admitted to the 
 
 Children's Hospital in December, 1887. The first 
 event in his case was chorea, accompanied at the 
 time by no other phase of rheumatism, and attributed 
 to fright (November, 1886). The second event was 
 a second attack, likewise unaccompanied by any other, 
 manifestation of rheumatism, and attributed to fright 
 (August, 1887). Up to this .period there had been 
 
22 COMBINATIONS OF THE RHEUMATIC SERIES 
 
 no arthritis, but two mouths later it came in a 
 group of phases comprising the third manifestation — 
 viz. arthritis, evolution of large nodules, endocarditis 
 (November and December, 1887) ; then a period of 
 rest for nearly six months; after which came the 
 fourth group of events, comprising a third attack of 
 chorea with emotional seizures, a second eruption of 
 nodules, pleurisy, pericarditis (June, 1888) ; and, 
 lastly, the fifth and final manifestation — recurrent 
 endocarditis, pericarditis (in July, 1888), and death 
 (August, 1888), when the pericardium was found 
 enormously thickened, the aortic and tricuspid valves 
 thickened, and the mitral thickened to a remarkable 
 degree. In this case, intensely rheumatic, which 
 ended fatally, it is deserving of notice that two 
 attacks of chorea at intervals of a year, both attri- 
 buted to fright, preceded the first known attack of 
 articular rheumatism ; and also that the persistent 
 endocarditis and pericarditis marched pari passu 
 with the evolution of nodules. 
 
 Such, gentlemen, are some of the combinations 
 of the rheumatic series. They are all taken from 
 actual cases ; but the list is not exhausted ; the 
 varieties are numerous, as numerous perhaps as the 
 combinations and permutations possible with the 
 eight phases I have named as commonly rheumatic. 
 
INFLUENCE OF SEX 23 
 
 But the brief summaries I . have given will serve 
 perhaps to exhibit the disease in its different out- 
 breaks, extending over months or years, as one 
 connected whole, instead of the fragmentary view 
 afforded by a single phase, or the less numerous 
 phenomena of the rheumatism of adult life. 
 
 Before I pass on to the consideration of each 
 phase of rheumatism in detail there are two other 
 characteristics of rheumatism in childhood to which 
 I must make some allusion. One is the incidence 
 of the disease upon the two sexes : the other the 
 influence of inherited constitutional predisposition. 
 
 Taking- first the influence of sex. The incidence 
 of articular rheumatism upon males and females 
 exhibits marked contrasts and variations at different 
 periods of life. I ask your attention to this, because 
 it has an important bearing upon the rheumatic con- 
 nection of chorea and heart disease, which I shall 
 have to point out later. Taking males and females 
 of all ages together, articular rheumatism is some- 
 what more common in the former. The statistics of 
 the Collective Investigation Committee of the British 
 Medical Association 1 yield in 655 cases 375 males to 
 279 females. 2 Up to the age of twenty, however, the 
 
 1 Collective Investigation Record, vol. iv. 1888, p. 67. 
 
 2 The statistics collected by Senator from various sources (Ziems- 
 sen's Cyclqpadia, vol. xvi. p. 18) give somewhat conflicting results; 
 
24 SPECIAL PROCLIVITY OF GIRLS 
 
 balance is the other way. For this period there is a 
 preponderance of females. The Collective Investi- 
 gation Statistics yield 108 males to 120 females. 1 
 After twenty the males are enormously in excess — 
 viz. 263 to 158. 2 Yet further, this preponderance 
 of females over males in early life is not uniform at 
 all periods of this first twenty years, but shows a 
 remarkable variation, which is, I think, of consider- 
 able significance. Taking periods of five years from 
 one to twenty years, it appears that in the first, one 
 to five years of age, boys preponderate — viz. 5 to 1. 
 At the next quinquennial period, between five and 
 ten years, they become nearly equal — viz. 15 boys to 
 14 girls. At the next period, eleven to fifteen years 
 of age inclusive, comes a remarkable change. The 
 proportion is suddenly and decisively reversed. Dur- 
 ing this quinquennial period girls suffer from arti- 
 cular rheumatism in great preponderance — viz. 47 
 
 but collectively yield a similar preponderance of males — viz. 1499 
 to 1425 females. 
 
 1 Collective Investigation Record, vol. iv. p. 67. 
 
 - The general preponderance of girls over boys is borne out by 
 other statistics. The records of cases of articular rheumatism at the 
 Children's Hospital in Great Ormond Street for twenty-six years give 
 _irls to 327 boys. In this case the limit of age is for one period 
 ten years, and for another twelve, so that it excludes a large propor- 
 tion of cases between eleven and fifteen, when girls most predomi- 
 nate. Dr. Goodhart's statistics give 42 girls to 27 boys (Diseases of 
 Children, p. 510). 
 
AGE AT WHICH IT BEACHES ITS MAXIMUM 25 
 
 girls to 25 boys, or nearly two to one. After fifteen 
 there is another change; the greater liability of 
 girls gradually declines up to twenty, so that at the 
 close of this period males again preponderate — viz, 
 76 to 67. l The greater proclivity of females, which 
 has been noted up to twenty years of age, is then, in 
 reality, chiefly due to their extraordinary liability 
 to the disease during this particular period of from 
 eleven to fifteen. A strong confirmation of this 
 special susceptibility of young girls to rheumatic 
 arthritis is afforded by the fact that the rule holds 
 with regard to scarlatinal rheumatism. According to 
 the statistics of 652 cases of scarlatina at the South- 
 western Fever Hospital noted by Dr. Gresswell, to 
 whom I am greatly. indebted for calling my attention 
 to the point and for this information, it appears that 
 the incidence of scarlatinal arthritis in girls and boys 
 between three and ten years of age is about equal, 
 just as in ordinary rheumatic arthritis — viz. four 
 boys in 176 cases, 5 girls in 179 cases ; between ten 
 and fifteen, boys in 42, girls 4 in 71, again in 
 harmony with the results in ordinary rheumatism. 
 The numbers are small, but as. far as they go support 
 . the special susceptibility of girls to rheumatic 
 
 1 Collective Investigation Becord, vol. iv. 1888. (Analysis of 
 cases there given.) 
 
26 INFLUENCE OF HEREDITARY PREDISPOSITION 
 
 arthritis. 1 So that, if these statistics hold good, girls 
 from the age of ten to fifteen are about twice as 
 liable to articular rheumatism as boys, in striking 
 contrast to all other periods, when males prepon- 
 derate. It will appear later that this greater liability 
 of girls to rheumatic arthritis during this period 
 corresponds with a similar liability to endocarditis 
 and chorea. 
 
 The second point, the influence of family predis- 
 position, comes out very clearly in the case of 
 children. The tendency to rheumatism is trans- 
 mitted as strongly as the tendency to gout. This is 
 more striking than in the case of adults : partly, 
 perhaps, for the reason that the constitutional ten- 
 dency existing is usually excited into activity- before 
 maturity — if it is there, it comes out in childhood ; 
 and partly, perhaps, because of the greater ease with 
 which the history of relatives is obtained in the case 
 of children. The parents supply information about 
 their own generation and that of their children ; 
 while grown persons, amongst the poor at any rate, 
 know little, and forget much of the generation which 
 
 1 The susceptibility appears, however, to be more prolonged than 
 in simple rheumatism. Taking the period ten to twenty-five years, 
 the numbers are : boys, 2 cases of arthritis out of 80 cases of 
 scarlatina; girls, 12 cases out of 118. Yet this is, of course, on the 
 whole, a further confirmation of the special liability of young 
 females. 
 
EVIDENCE OF THIS 27 
 
 preceded them. The estimates of the extent of this 
 transmission vary according to the minuteness of 
 inquiry made, and the evidence allowed as sufficient 
 to establish the existence of the rheumatic state. Sir 
 A. Garrod traced it in about 25 per cent. Dr. A. B. 
 Garrod, 1 taking adults and children together, esti- 
 mates it at 35 per cent, in rheumatic patients, as 
 compared with 20 per cent, in non-rheumatic patients. 
 These estimates are necessarily under the mark, since 
 they are founded solely upon the occurrence of well- 
 marked attacks of acute articular rheumatism, and 
 chiefly in adults, all evidence afforded by minor attacks 
 or combination of other phases, such as heart disease, 
 chorea, nodules, &c, not being taken into account. 
 Dr. Goodhart, 2 taking children alone, found satisfac- 
 tory evidence of rheumatic affection in 41 out of 69, 
 or 57 per cent. The influence of hereditary predis- 
 position is well shown by some statistics I have had 
 drawn up, for which I am indebted to the late regis- 
 trar at the Hospital for Sick Children, Dr. Chaffey. 
 Taking 592 cases of children admitted for diseases 
 of all kinds, both medical and surgical, careful in- 
 quiry was made into the family history with regard 
 to acute rheumatism. In 173 there was clear history 
 
 1 The Lancet, July 21, 1888. 
 
 2 Diseases of Children, p. 512. 
 
28 EXAMPLES OF FAMILY PREDISPOSITION 
 
 of acute rheumatism in immediate blood-relatives. 
 Of these 173, 38 had developed unmistakable rheu- 
 matic affection, equal to 20 per cent. If slighter 
 arthritis, chorea, heart disease, and other less certain 
 manifestations, were admitted as evidence, this pro- 
 portion would of course be largely increased. Taking 
 now the remaining 319 in whom no history of joint 
 affection in immediate blood-relatives could be traced, 
 only 15 developed articular rheumatism, equal to 4*5 
 per cent. So that with a family history of acute 
 rheumatism in immediate blood-relatives the chance 
 of an individual with such hereditary tendency con- 
 tracting acute articular rheumatism is nearly five 
 times as great as that of an individual who has no 
 such hereditary taint. I may give a few examples to 
 illustrate this influence of family predisposition. 
 
 George L , aged eight, was admitted to Great 
 
 Ormond Street for advanced mitral disease of the 
 heart. He had had rheumatic fever four years be- 
 fore, followed by two attacks of chorea. His father 
 had rheumatic fever as a child, and died of valvular 
 disease of the heart. His father's sister had rheu- 
 matic fever three times. The father's brother had 
 subacute rheumatism. 
 
 Take another instance. George H. S — .— , aged 
 nine vears and five months, was admitted to Great 
 
EXAMPLES OF FAMILY PREDISPOSITION 29 
 
 Ormond Street with, slight articular rheumatism, 
 ushered in by tonsillitis. On examination a loud 
 mitral regurgitant murmur and an aortic regurgi- 
 tant murmur were found, with great hypertrophy. 
 He must have had endocarditis long before, yet there 
 was no history of any previous joint affection. His 
 mother bad had rheumatic fever; his mother's sister 
 rheumatic fever, followed by chorea; another sister 
 of the mother rheumatic fever ; the father had rheu- 
 matism, but of doubtful nature. 
 
 But these instances of family predisposition, of 
 which I could furnish almost any number, are quite 
 eclipsed by a case published by Dr. Goodhart in vol. 
 xxv. of Guy's Hospital Reports, where, ' with a rheu- 
 matic strain in both, father and mother, five out 
 of six children under fifteen — i.e. all but a baby of 
 fourteen months — had either articular rheumatism 
 or heart-disease. A boy of fifteen had had rheumatic 
 fever twice, and had mitral regurgitation; the second, 
 a boy of ten, the same ; the third, a girl of eight, died 
 of mitral disease ; the fourth, a girl, had rheumatic 
 fever after scarlatina, followed by mitral disease; 
 the fifth, a boy of four, was laid by all winter with 
 rheumatism.' ' And Dr. Goodhart mentions the case 
 recorded by Steiner in his ' Diseases of Children,' 
 which shows this proclivity in a still more extra- 
 
30 SPECIAL CHARACTERS OF ARTHRITIS 
 
 ordinary degree. A rheumatic mother had twelve 
 children, and eleven of them had rheumatism before 
 the age of twenty. Now it occurred to me that this 
 extraordinary tendency of rheumatism to develop in 
 certain families might be due to some special faults 
 of locality or circumstances, but careful inquiry into 
 a number of cases showed me that they arose in very 
 various localities, in members of the family when in 
 different places and under different conditions. 
 
 Having thus reviewed broadly the general charac- 
 teristics of the rheumatism of childhood — viz. the 
 comparative insignificance of the articular affection ; 
 the prominence and importance of other phenomena, 
 some of which, such as nodules and chorea, are 
 limited to early life ; the tendency of these phe- 
 nomena to appear independently, scattered singly or 
 in groups through a considerable period ; sometimes 
 one, sometimes another, appearing as the primary 
 phase, and the others in varying order of succession; 
 the influence of sex, and of hereditary predisposition, 
 — I pass on to the consideration of the various phases 
 in detail. The first — the arthritis, or articular rheu- 
 matism — differs in many notable features from the 
 acute articular rheumatism of later life. I have al- 
 luded already to the fact, sufficiently recognised, that 
 the articular affection is usually comparatively slight 
 
IN CHILDHOOD USUALLY SLIGHT 31 
 
 and may even be absent altogether. It is however, 
 I believe, nearly always present at some period of the 
 rheumatic efflorescence. I have now under my care 
 
 at St. Mary's Hospital, Kate B , a girl of fifteen, 
 
 who was admitted with severe chorea. There was 
 no sign of articular affection, or of any other condi- 
 tion suggestive of rheumatism. The heart's sounds 
 were clear and natural. There was no history of 
 any previous rheumatic affection of any kind to be 
 obtained by most careful inquiry, there was no his- 
 tory of rheumatism of any form in the family, and 
 the case was put down as an instance of non-rheu- 
 matic chorea. Twelve days after admission, however, 
 she suddenly complained of pain and stiffness of the 
 right wrist and back of the hand, which were found 
 to be slightly but unmistakably swollen and tender. 
 The arthritis subsided in forty-eight hours. Three 
 days later a similar pain and tenderness of the right 
 wrist and hand developed, subsiding as quickly as 
 the first. It would certainly have escaped serious 
 notice had not my house physician been on the watch 
 for the possible appearance of some rheumatic sign. 
 Such cases give the key to many instances of unex- 
 plained heart disease and chorea. 1 The arthritis is, 
 
 1 This has subsequently received further illustration and con- 
 firmation. Since the above was written, and three weeks after the 
 occurrence of the transient arthritis above recorded, pericarditis has 
 
32 RARITY OF SEVERE ARTICULAR AFFECTION 
 
 indeed, less extreme in every way ; there is less swell- 
 ing and tenderness and pain. It is a comparatively 
 rare thing to see a little child lying still and motion- 
 less, bound hand and foot, not daring to move or 
 turn for fear of pain — the condition so character- 
 istic of the disease in an adult. There is often 
 merely a little pain and a little stiffness and tender- 
 ness, limited perhaps to a single joint or set of joints, 
 hardly attracting notice, soon forgotten, often over- 
 looked altogether, and constantly never severe. enough 
 for the doctor's aid to be called in. It is subsequent 
 heart disease which sends these cases to hospital. 
 Often when medical advice is sought the ailment 
 passes for nothing but a slight feverish attack. Such 
 cases are constantly described as 'low fever.' And, 
 as the inflammatory condition is slight, so many signs 
 met with in severe rheumatic arthritis are wanting. 
 The profuse sweating, the intensely acid, sour-smelling 
 perspiration, which is one of the typical symptoms 
 in the acute rheumatism of adults, is rarely seen in 
 that of children, the rarity being in inverse propor- 
 tion to age. It only begins to appear with more 
 severe joint affection as age advances, and is rarely 
 extreme before puberty. Other conditions, again, 
 
 supervened. The chorea has disappeared, and there is no articular 
 atfection. 
 
CHARACTER OF THE PYREXIA 33 
 
 associated with the profuse sweating are also want- 
 ing. The sudamina and miliary eruption which so 
 often accompany it in adults are rarely if ever seen 
 in children. And as the inflammation of joint 
 structures is slight, so also is the pyrexia. The tem- 
 perature seldom runs high ; and this is the more 
 remarkable because, as a rule, it rises readily in 
 children — goes up suddenly for a slight cause to 104° 
 or 105°, perhaps from such trivial disturbance as a 
 dose of irritant food or a passing chill. Moreover, 
 many more structures are involved, so that it must be 
 chiefly arthritis which raises temperature. Yet here, 
 in this eminently pyrexial affection, it seldom rises 
 in children above 101° or 102° ; 103° and 104° are 
 comparatively uncommon, and such rise is usually 
 of short duration. Look at the case of S , for in- 
 stance, given in Series VIII. As you will see, during 
 his stay in hospital from December, 1887, to March, 
 1888, a period of four months, he had articular rheu- 
 matism, eruption of nodules, endocarditis, and tonsil- 
 litis, in addition to chorea and erythema, and died of 
 the disease at last. Yet his temperature was chiefly 
 subnormal, rising only once to 101° for a single 
 night, and once to 100° for a like period. Take, 
 
 again, the case of John T , given in Series X. 
 
 He was in hospital for nine months almost con- 
 
34 RARITY OF HYPERPYREXIA 
 
 tinuously. He had, amongst other rheumatic phases 
 during his stay, arthritis, endocarditis, pericarditis, 
 pleurisy, a pulse of 120 to 130, and the disease 
 steadil} r progressed to a fatal ending. He died of 
 recurrent pericarditis. Yet his highest temperature 
 was 101*5°; for two short periods only did it reach 
 101°; for the rest it rarely reached 100°. Hyper- 
 pyrexia, which occurs now and again in the acute 
 rheumatism of adults, and is in them so grave and 
 dangerous, often absolutely uncontrollable, is rare in 
 childhood. I have never seen a case of fatal hyper- 
 pyrexia in a child, and I can find no instance in which 
 the temperature has shown a persistent tendency 
 to run up rapidly beyond control to a fatal height. 
 Dr. Fagge observed l that in fourteen cases of fatal 
 rheumatic hyperpyrexia at Guy's Hospital, all but 
 two were over twenty years of age, and these were 
 a boy of nineteen and a girl of eighteen. In Dr. 
 Wilson Fox's 2 twenty-two cases of rheumatic hyper- 
 pyrexia the youngest was a girl of seventeen. Dr. 
 Barlow 3 mentions a case of fatal rheumatic hyper- 
 pyrexia in a girl of thirteen, but he does not give 
 the range of temperature, or state that hyperpyrexia 
 
 1 Principles and Practice of Medicine, vol. ii. p. 546. 
 
 2 Treatment of Hyperpyrexia,^. 71-77. 
 
 3 Brit. Med. Jour., September 15, 1883, p. 013. 
 
EXAMPLES OF ARTHRITIS IN CHILDREN 35 
 
 was the direct cause of death by running up uncon- 
 trollably to a fatal height. 
 
 The slight arthritis of childhood often assumes a 
 misleading aspect, and it is sometimes difficult to 
 distinguish it from other ailments involving pain and 
 tenderness of parts. Their recognition is of immense 
 importance, since a deadly endocarditis or pericar- 
 ditis may be insidiously developing concurrently. I 
 give one or two clinical examples of errors of the 
 kind. 
 
 M. T -, a girl of three, was observed to be 
 
 slightly feverish and ailing on February 10. On the 
 12th the great toe of one foot was found to be 
 swollen and tender. On the 13th she was brought 
 to me. The child had a white and dry tongue ; 
 pulse 120 ; temperature 103°. The swelling and 
 tenderness of the toe were supposed to be due to 
 chilblain. No other joints were affected, but the 
 pulse and temperature suggested articular rheu- 
 matism. The heart-sounds were clear. Two days 
 later (February 15) both feet and ankles were slightly 
 stiff, tender, and swollen, and movement of them was 
 painful ; temperature 102°. On examining the heart, 
 a soft murmur was audible at the apex. The follow- 
 ing day the pain and stiffness of joints were almost 
 gone ; temperature 99°. The cardiac murmur had 
 
 D 2 
 
36 EXAMPLES OF ARTHRITIS IX CHILDREN 
 
 become full and blowing. This murmur persisted 
 for many weeks, and then gradually disappeared. 
 The father's sister and her child had both had acute 
 rheumatism, and the former pericarditis and mitral 
 valvulitis also. 
 
 Take another case I saw in consultation a few 
 years ago — a little girl four years old. The child 
 had had for a week or ten days difficulty in putting 
 the right heel down, and was supposed to have 
 incipient talipes, for which she had been galvanised 
 steadily without result. The difficulty in putting 
 down the heel had subsided, but the child still 
 showed the greatest disinclination to walk. I. could 
 find no deformity or distortion, but I found both 
 knees unmistakably swollen and tender, especially 
 the left. The temperature was 100°. It turned out, 
 too, upon inquiry, that the girl had suffered from 
 pains and stiffness in the knees and ankles from time 
 to time for the previous six months ; and further, 
 the mother had had rheumatic fever. I had no doubt 
 that the joint trouble was rheumatic. Under salicin 
 and citrate of potash all tenderness and stiffness dis- 
 appeared, and in a day or two the child was running 
 about as usual. 
 
 Here is another example. E. C , a boy five 
 
 years old, was brought to me because he had suddenly 
 
EXAMPLES OF AETHRITIS IN CHILDREN 37 
 
 become unable to walk when he got out of bed in 
 the morning. He was most reluctant to attempt it, 
 but when made to do so he went on tiptoe with bent 
 knees; any attempt to straighten the knees gave 
 pain. The ham-tendons were rigid and very tender. 
 There was no swelling. The temperature was 103°. 
 The heart's action was much excited, but there was 
 no bruit. It appeared that the mother had had 
 rheumatic fever and acute pericarditis, and exami- 
 nation showed a loud mitral murmur. Salicin was 
 given freely, and in twenty-four hours the stiffness 
 and tenderness had so far declined that the child 
 was able to walk, and the temperature had gone down 
 to 100°. 
 
 Another example which I think throws great 
 light upon cases of valvular disease of the heart of 
 
 unexplained origin is that of Ernest C , a boy 
 
 who was admitted into the Children's Hospital with 
 a loud mitral regurgitant murmur, heaving, diffused 
 impulse, bulging prsecordia, and other signs of 
 hypertrophy and dilatation. He had never been 
 observed to have any articular affection or chorea, or 
 other sign of rheumatism. There was no family 
 history of rheumatism. Three weeks after admission 
 he suddenly complained of pain in one knee, and could 
 not bear to straighten it or use it in walking. The 
 
38 AFFECTION OF HAMSTRING TENDONS 
 
 tendons on each side of the popliteal space and its 
 lower border were fonncl tense, swollen, rigid, and 
 extremely tender. There was a slight rise of tem- 
 perature. In view of the mitral disease, there could 
 be little doubt that the affection of the knee was 
 rheumatic, and that the valvular disease was likewise 
 the result of rheumatic endocarditis, possibly accom- 
 panied by some slight arthritis which had escaped 
 with little notice and long been forgotten. This 
 affection of the tendons of the hamstring muscles 
 — the biceps, semi-tendinosus, semi-membranosus, 
 gracilis, and sartorius, — and walking with bent knees 
 on the tips of the toe to avoid tension of them, is, I 
 think, very characteristic. I have seen it now many 
 times in rheumatic children, and it is analogous to 
 the stiff neck and torticollis which is sometimes in 
 like manner the first or sole feature of a rheumatic 
 attack. Conversely, other conditions are often 
 mistaken for articular rheumatism. Essential 
 paralysis in its early stage, when there is great 
 hyperesthesia, is one of them. The chief points of 
 distinction are that in essential paralysis there is 
 extreme flaccidity of muscle, the limb falling limp 
 and loose, drooping of the toes, and the fact that the 
 tenderness in general is not confined to joints and 
 tendons. Later the disappearance of faradic con- 
 
CONDITIONS SIMULATING RHEUMATIC ARTHRITIS 39 
 
 tractility and tendon reflex would be decisive. I 
 have, however, now nnder my care at Great Ormond 
 Street a boy who had considerable rigidity about the 
 knees, the extension of which gave great pain. The 
 tenderness was, however, general, the toes drooped, 
 and faradic contractility had almost disappeared in 
 the affected muscles. 
 
 Another condition which is liable to be mistaken 
 for slight rheumatic arthritis is syphilitic disease of 
 the ends of the long bones. In this there are tender- 
 ness and swelling from accompanying periostitis, and 
 there maybe even some arthritis, the limbs, being 
 kept motionless from pain on movement. It may be 
 distinguished by the presence of other signs of con- 
 genital syphilis, and by the history possibly ; but the 
 age at which it occurs — viz. in the first few months 
 after birth — is almost diagnostic. Rheumatic arth- 
 ritis is almost, if not quite, unknown in early infancy. 
 I have never seen it under two years, although Dr. 
 Goodhart has noted some doubtful cases in children 
 of two or three months, and Henoch records one at 
 ten months. Senator has collected several cases in 
 infants, one at four weeks old. 
 
 Another condition which has been mistakenly re- 
 garded as rheumatic is the tenderness, swelling, and 
 immobility of the limbs which arise in infantile scurvy 
 
40 CONDITIONS SIMULATING RHEUMATIC ARTHRITIS 
 
 — the so-called scurvy-rickets. This is to be distin- 
 guished by the swellings being limited usually to the 
 shafts of the long bones, although I have once seen 
 a periosteal swelling on the malar bone and swelling 
 and tenderness of the joints. Such, however, are 
 rare exceptions. Other diagnostic points are the exis- 
 tence of spongy gums, subcutaneous haemorrhages, 
 and albuminuria. And then infantile scurvy is 
 limited to the bottle-feeding period — i.e. the first 
 eighteen months or two years, when articular 
 rheumatism is almost unknown. The swelling of 
 the wrists in tetany, the arthritic haemorrhages of 
 haemophilia, the joint trouble of strumous disease, 
 and pyaemic arthritis, are all conditions liable to be 
 mistaken for articular rheumatism. I have only 
 time to call attention to them as possible sources of 
 error. 
 
41 
 
 LECTUEE II. 
 
 The Anasmia of Bheuniatisni — Tonsillitis, its relation to rheumatism 
 — Erythema exuclativum — Erythema nodosum — Purpura rheu- 
 matica — Chorea, its place in the rheumatic series — Subcutaneous 
 nodules, their character and structure — Mode of evolution — Rare 
 in adult life — Pathological and clinical significance — Pleurisy — ■ 
 Occurs in two distinct ways : (1) late, in relation to cardiac 
 disease, as a result of mechanical congestion ; and (2) as a 
 primary manifestation of rheumatism. 
 
 Ancemia. — The effect of rheumatism in producing 
 anaemia in adults is sufficiently well known, but in 
 children this is still more remarkable ; the extreme 
 pallor and the hsemic murmurs are often most notable. 
 Dr. Goodhart l thinks, further, that even children of 
 rheumatic parentage are often habitually anaemic. 
 Others, again, have regarded anaemia as a predis- 
 posing cause of rheumatism. It may be that the 
 inherited rheumatic taint gives the tendency to an- 
 gemia, and thus the rheumatism is the antecedent of 
 the anaemia, not the anaemia of the rheumatism. Be 
 this as it may, however, where the rheumatic state 
 
 1 Diseases of Children, p. 515. 
 
42 THE AX.EMIA OF RHEUMATISM 
 
 is actively developed, anaemia proceeds apace in 
 children. The presence of the rheumatic poison 
 appears to be inimical to the red corpuscles or their 
 haematin ; it either promotes their disintegration or 
 interferes with their production. Trousseau l affirms 
 that there is, perhaps, no acute disease which pro- 
 duces anaemia so rapidly as rheumatism ; but this is not 
 so. The rheumatic poison is not so rapidly destruc- 
 tive of red blood as that of diphtheria, which causes 
 marked blanching in the course of a few days ; but 
 still its effect is decided and unmistakable. This in- 
 fluence of rheumatism in producing anaemia is greatly 
 aggravated when it is accompanied by valvular 
 disease of the heart and pericarditis. The deficient 
 circulation through the lungs — the deficient oxygena- 
 tion — may, in part, account for this ; and it is accom- 
 panied, also, by progressive emaciation. Of this, 
 however, I shall speak in the concluding lecture. I 
 have now under my care a child with chorea and 
 pericarditis. There is no arthritis, but the patient 
 has had articular rheumatism before. The anaemia 
 is extreme ; the pallor that of a marked chlorosis. 
 
 Tonsillitis. — The claim of tonsillitis to be ranked 
 as one of the rheumatic series is, I think, well 
 established. Tonsillitis is a common disorder, and 
 
 1 Clin. Med., vol. iv. p. 454. 
 
TONSILLITIS 43 
 
 often arises independently ; but it occurs so frequently 
 in direct and immediate association with articular 
 rheumatism that some pathological connection can- 
 not be doubted. Trousseau 1 recognised a rheumatic 
 sore-throat, and showed how this was apt to alter- 
 nate at one time with stiff neck and torticollis, at 
 another with joint pain and lumbago. Attention 
 was again drawn to the almost forgotten observation 
 of Trousseau by Dr. Kingston Fowler 2 in 1880, who 
 published an account of twenty cases of acute rheu- 
 matism ushered in by tonsillitis. The statistics of 
 the Collective Investigation Committee 3 show that 
 tonsillitis was associated with rheumatism in 158 
 cases out of 655, or 24*12 per cent., in addition to 
 twenty cases of sore-throat, the exact nature of which 
 was not described. If these were added the proportion 
 would be 27*17 per cent. 4 It is assumed, I think, 
 generally, that tonsillitis always precedes the articular 
 affection, and usually comes immediately before it — 
 ushers it in, as the phrase goes ; and this is no doubt 
 the rule, but it is by no means invariable. Tonsillitis 
 may occur at any period of the rheumatic series, 
 although most often it comes first — immediately 
 
 1 Clin. Med. vol. ii. p. 466. - Lancet, December 11, 1880. 
 
 3 Brit. Med. Jour. : Dr. Whipham's Eeport, Feb. 25, 1888, p. 391. 
 
 4 Dr. Fowler estimated it as occurring in 80 per cent, of cases. 
 
44 ITS PLACE IX THE RHEUMATIC SERIES 
 
 preceding arthritis. 1 In all bnt three of the 158 
 cases just quoted the tonsillitis preceded the arthritis 
 at various intervals ; in two of the remaining three 
 cases the tonsillitis accompanied the joint affection, 
 and in the third followed it. In the fatal case of W. 
 
 S , shown in Series VIII. , it came last of all. In 
 
 the case of William K , a boy of eight, recently 
 
 under my care, it likewise occurred last of a series 
 beoinninor with arthritis and endocarditis ; four 
 months later, chorea ; at the close of the chorea, acute 
 tonsillitis. My own boy, of whose case I have spoken 
 as having exhibited almost all the phases of rheu- 
 matism except carditis, had tonsillitis during the 
 period of arthritis, and constant, repeated, and severe 
 attacks during the period of chorea, and for a con- 
 siderable term after all other signs of rheumatism had 
 ceased. Of four other children, not one has suffered 
 from tonsillitis, although all have been brought 
 up together under like conditions. Whether the 
 tonsillitis set up by rheumatism presents any distinc- 
 tive characters, I cannot say with certainty. Trous- 
 seau affirmed that it could be distinguished by its 
 ephemeral character, lasting only from thirty to 
 
 1 Dr. Archibald Garrod and Mr. Cooke, in a paper published in the 
 Lancet, July 21, 1888, found the percentage of cases of tonsillitis 
 with rheumatic family history exactly the same as the percentage 
 of articular rheumatism with rheumatic history — viz. 35 per cent. 
 
CHARACTERS OF RHEUMATIC TONSILLITIS 45 
 
 forty-eight hours, and he describes the rheumatic 
 sore-throat as something more than tonsillitis, in- 
 volving the pharynx, soft palate, and uvula. In 
 some cases which I have observed, the diffused 
 character of the inflammatory redness and swelling 
 was very marked ; but I do not know that this is 
 invariable ; further observation is needed on this 
 point. It is probable that tonsillitis may occur as a 
 solitary expression of the rheumatic state. In many 
 cases it arises in rheumatic subjects quite apart 
 from the articular manifestation. Of its concurrence 
 with another rheumatic affection — viz. chorea — I 
 have seen three examples quite recently, and in all 
 these the chorea occurred in a child who had articu- 
 lar rheumatism at another epoch. But of its con- 
 nection with endocarditis or pericarditis apart from 
 arthritis I have no certain knowledge. 1 Tonsillitis 
 
 1 I have not traced the connection ; but, curiously enough, as I 
 was in the act of writing this portion of my lecture I was asked by 
 Mr. Kiallmark to see, in consultation with him, a little boy of six 
 suffering from relapsing tonsillitis, in whom he had discovered, to 
 his dismay, a distinct apex murmur. The child had had previous 
 attacks, and Mr. Kiallmark had judged them to be rheumatic. The 
 boy has had no arthritis, and there is no distinct rheumatic family 
 history. The tonsillitis rapidly got well under salicylate of soda, 
 recurring three times when this medicine was omitted. The mur- 
 mur is a soft one, audible over the tricuspid area, not at the apex. 
 I am doubtful whether it is organic, but I shall be much interested 
 to learn its future course. 
 
46 ERYTHEMA EXUDATIVUM 
 
 is set up by many other causes as well as by rheu- 
 matism. The decision whether a given case of 
 tonsillitis not immediately associated with articular 
 rheumatism is of rheumatic nature must be based 
 upon a comprehensive survey of the patient's life 
 history and family predisposition, as well as of the 
 accompanying symptoms. If it occurs in a child 
 with a strong family history of acute rheumatism, 
 or in one who has had articular affection, this is 
 presumptive evidence in favour of the • tonsillitis 
 being rheumatic. Even if there has been no arth- 
 ritis at any time, the concurrence of other members 
 of the rheumatic series — such as subcutaneous 
 nodules, chorea, endocarditis, pericarditis, or ery- 
 thema — would afford evidence weighty in proportion 
 to the particular phases developed, the completeness 
 of the combination, and the extent of the series. 
 
 Erythema exudativum. — The connection of ery- 
 thema exudativum with the rheumatic state appears 
 much more clearly in the case of children than of 
 adults. With the latter it occurs occasionally ; with 
 children, according to my experience, it is common. 
 The statistics of the Collective Investigation Com- 
 mittee give only thirty-two cases out of 655, or not 
 quite 5 per cent. ; but these contain very few chil- 
 dren — only fifty- one under twelve. Dr. Barlow and 
 
THE MAHGINATE AND URTICAEIOUS FORMS 47 
 
 Dr. Warner found that, of twenty-seven patients 
 with rheumatic nodules, eight had erythema papu- 
 latum or marginatum, one urticaria, and one pur- 
 pura — i.e. ten out of twenty- seven, and these in 
 close association with the evolution of the nodules. 
 It appears in various forms — erythema marginatum, 
 erythema papulatum, erythema nodosum, and urti- 
 caria, the first named being the most common. The 
 erythema may occur at any point in the rheumatic 
 series ; but it is usually, at any rate, associated with 
 the development of active rheumatic disturbance of 
 some other kind, and occurs chiefly in the marginate 
 or urticarious form. These varieties are not mi- 
 frequently associated with endocarditis and pericar- 
 ditis in the more serious cases. In eight cases of 
 extreme gravity which have come under my care 
 within the last year, four of which were fatal from 
 persistent recurrent pericarditis and endocarditis, 
 erythema of this kind occurred in one-half — two of 
 the fatal cases and two others. Dr. Barlow, in his 
 excellent introduction to the discussion of rheuma- 
 tism at the meeting of the British Medical Associa- 
 tion at Liverpool in 1883, refers to a case under 
 his observation in which erythema occurred as one 
 of a group in the rheumatic series, associated with 
 endocarditis, pleurisy, and pneumonia, but without 
 
48 ERYTHEMA NODOSUM 
 
 arthritis ; the arthritis had occurred years before. 
 He mentions another case, also under his own obser- 
 vation, where erythema appeared as one of a group 
 of rheumatic phenomena, which included nodules, 
 chorea, and fatal pericarditis, but no arthritis ; that 
 had occurred in a previous explosion of rheumatic 
 activity. Dr. Barlow also gives two other cases in 
 which exudative erythema ushered in rheumatic 
 seizures — including endocarditis and pericarditis, 
 with arthritis following. 
 
 With regard to the special form erythema no- 
 dosum, it would appear that, although it has, so 
 to speak, an arthritis of its own, it is associated 
 sometimes with true articular rheumatism. The 
 eruption is attended in itself with pain of joints, 
 and sometimes swelling, possibly from pressure. 
 But it also arises in connection with genuine acute 
 articular rheumatism. Sir Thomas Watson observed 
 it to occur both before and after this affection, and 
 quotes Bayer as having seen it in the same con- 
 nection. I have just had under my care, in Great 
 Ormond Street, a case which is interesting as illus- 
 trating the rheumatic connection, the concurrence 
 of endocarditis, and also the occurrence of this erup- 
 tion at an early age. Walter G , aged two 
 
 years and eight months, was admitted on October 1 
 last with well-marked erythema nodosum on both 
 
RELATION OF ERYTHEMA TO RHEUMATISM 49 
 
 shins. There was no arthritis, or any history of 
 its previous occurrence at any period, yet the child 
 has a well-marked mitral regurgitant murmur, un- 
 doubtedly organic. The father had had ' rheuma- 
 tism,' and the father's sister rheumatic fever twice. 1 
 The tendency of erythema nodosum to occur especi- 
 ally in young girls — who are also most liable to 
 rheumatic arthritis, to endocarditis, and to chorea 
 —is in agreement with the view of its rheumatic 
 nature ; yet exudative erythema, although often 
 rheumatic, is, like arthritis and tonsillitis, set up 
 by other causes than rheumatism. The facts that 
 erythema occurs in cholera and in septicaemia as the 
 result of poisoning by certain drugs, and the urti- 
 carious form by food-poisoning, suggest a similar 
 influence- of the rheumatic poison, and we should 
 look at the appearance of erythema in any given 
 case as probably indicative of the existence of some 
 irritant matter which is in circulation acting either 
 directly or by reflection upon the skin. Such irri- 
 tant may be the rheumatic virus ; whether it is so 
 or not must be determined by careful examination 
 
 1 Since the above was written I have met with an instance of 
 erythema nodosum occurring together with subcutaneous tendinous 
 nodules, apart from any other rheumatic manifestation except ton- 
 sillitis (F. V set. 81, St. Mary's Hosp., Feb. 1889). 
 
 E 
 
50 PURPURA RHEUMATICA 
 
 of the evidence afforded by the presence or absence 
 of other members of the rheumatic series, or by their 
 previous occurrence, together with the existence or 
 otherwise of family predisposition. 
 
 Purpura rheumatica. — This appears especially in 
 rheumatic subjects, and, like erythema nodosum, has 
 a local ^tasi-arthritis of its own ; when it appears 
 on the legs and ankles, the ankle-joints and feet are 
 swollen, tender, and painful. But it arises also in 
 the course of general acute articular rheumatism, as 
 I have seen more than once ; although usually, I 
 think, it occurs independently. In one case, the 
 patient whom I have mentioned before, a boy of eight 
 (Series VII.) had had acute rheumatism severely 
 twelve months before. The eruption appeared after 
 standing about in the wet grass while very hot from 
 playing cricket — a profuse crop of large purpuric 
 spots on both legs, mostly about the ankles. There 
 Avas much swelling of the ankle-joints, which were 
 so tender that he could not bear to walk or move 
 them ; but no other joints were affected, and there 
 were never any constitutional symptoms or the small- 
 est rise of temperature, although it was taken 
 frequently, from apprehension of a second attack of 
 rheumatic fever. From these two circumstances — 
 viz. that the ankles only were attacked, and that 
 
CHOREA 51 
 
 there was never any fever or general illness — I 
 conclude the swelling was not directly rheumatic, 
 but a local oedema, from purpuric extravasation or 
 thrombosis of venules. Purpura rheumatica, then, 
 while sometimes concurrent with active, acute, arti- 
 cular rheumatism, occurs also apart from it in rheu- 
 matic subjects, and is probably a minor expression 
 of the rheumatic state, although far less common 
 than exudative erythema. 
 
 Chorea. — This is one of the most interesting 
 members of the rheumatic series. When associated 
 with articular rheumatism it usually follows the 
 arthritis ; it is sometimes concurrent with it ; and 
 sometimes, again, as I have shown, and asM. Roger 
 noted long ago, it precedes the joint affection. In- 
 stances of this are shown in the clinical examples 
 given in the preceding lecture. Chorea has furnished 
 several curious pathological problems, which have 
 given rise to frequent discussions and controversies, 
 some of which continue to rage unsettled to this day. 
 All are agreed, I think, that there is a certain 
 connection between chorea and rheumatism. As Dr. 
 Barlow has well observed, there is no other general 
 disease or fever of childhood with which chorea has 
 any such association, with the single exception of 
 scarlet fever, and that in far less degree ; and scarlet 
 
 B 2 
 
52 THE RELATION OF CHOREA TO RHEUMATISM 
 
 'fever, significantly enough, is the one fever especially 
 associated with acute rheumatism. We never see a 
 measles chorea, or a whooping-cough chorea, or a 
 mumps chorea. The only points in dispute, then, 
 are the nature of such relation between chorea and 
 rheumatism, and its closeness and constancy. Some 
 hold with M. Soger that all chorea is rheumatic — 
 that it owns no other source ; others that the relation 
 is comparatively slight and rare. Statistics have 
 been supplied on each side, some supporting one 
 view, some another, varying perhaps in degree ac- 
 cording to the unconscious bias of the compiler. Let 
 me state clearly my own position on this question. 
 I do not think the evidence warrants the assumption 
 that chorea is invariably of rheumatic origin. I must 
 say of chorea, as of tonsillitis, erythema, endocarditis, 
 pericarditis, and arthritis— in fact, of the whole of 
 the rheumatic series except subcutaneous nodules— 
 that it is produced by other causes as well as by 
 rheumatism. But I am convinced that rheumatism 
 is the most common and potent factor. Other factors, 
 however, must be taken into account in forming any 
 satisfactory explanation of the genesis of chorea. 
 There is a physiological basis in that greater mobility 
 of nervous system and motor readiness of expression 
 so well described by Dr. Sturges, and in the more 
 
RELATION TO NEUROSES 53 
 
 excitable temperament of quick, intelligent children, 
 and of girls as compared with boys. This all tells 
 and plays a part in the development of chorea. Yet 
 it is singular how small the association with other 
 neuroses appears to be, at any rate as far as the in- 
 dividuals are concerned ; for these are found, accord- 
 ing to the Statistics of the Collective Investigation 
 Committee, 1 in 97 cases only out of 439, or a little 
 more than 22 per cent., and these 97 include 79 
 cases of headache and migraine, so that if there is 
 any pathological affinity it is with those special forms 
 only. Taking the question of inheritance, there is 
 what is termed a neurotic family history in no less 
 than 46 per cent. At first sight this seems significant, 
 but on examination the neurotic affections included 
 are such a motley crew that their presence in the 
 record does not carry much weight; for the list em- 
 braces paralysis, drunkenness, tubercular meningitis, 
 diabetes, sunstroke, spinal injury, and sciatica. 
 There is not, as might fairly have been expected, a 
 large proportion of hysteria (7*5 per cent.) The only 
 connection which comes out with any significance is 
 chorea itself (14 per cent.), and this probably re- 
 presents a rheumatic as much as a neurotic relation. 
 And while I am upon this subject, let me pause for 
 
 1 Coll. invest. Record, vol. iii. p. 54. 
 
54 FALLACY WITH REGARD TO MIMETIC CHOREA 
 
 a moment to explode a time-honoured fallacy in the 
 etiology of chorea — that is, that it spreads by imita- 
 tion. This was true of the dancing mania of the 
 middle ages, which spread amongst enthusiasts by 
 a sort of hysterical contagion. And children learn 
 certain tricks of grimacing. But they never acquire 
 true chorea by imitation any more than they acquire 
 nodules, or paresis, or endocarditis by imitation. 
 Dr. West, 1 indeed, speaks of it as occurring occa- 
 sionally, and of the necessity arising for changing 
 the position of patients, to prevent the involuntary 
 mimicry by one child of the movements of another. 
 In the Collective Investigation Report 2 two cases 
 are recorded as mimetic, but no details are given. I 
 have now been connected with the hospital in Great 
 Ormond Street for some twenty years. Cases of 
 chorea are extremely common there ; in the girls' 
 wards, especially, there are often five or six or more 
 cases at a time. It is very rarely, indeed, that there 
 are not some. They are placed indiscriminately with 
 other children, and yet I have not seen a single 
 instance of its spread by imitation. I believe the 
 separation of children to prevent mimetic develop- 
 ment of chorea is entirely unnecessary. The belief 
 
 1 Disease.', of Infancy and Childhood, seventh edition, p. 236. 
 ■ Vol. iii. p. 48. 
 
NERVOUS SHOCK Es T CHOREA 55 
 
 in its production in this "way is a survival of some 
 old tradition, or has arisen from mistaking a 
 trick of grimacing for true chorea. The statement 
 has got into text-books, and, like many other time- 
 honoured fallacies, holds its ground there, simply 
 because it is taken for granted without inquiry. In 
 speaking of grimacing, I may here also allude, in 
 passing, to the minor chorea, which consists in mere 
 winking of the eye and twitching of the lips or nose, 
 without jactitation of the limbs. This is, I believe, 
 usually a local chorea, connected with the eruption of 
 the second teeth, and especially of the eye-teeth, and 
 not, I think, essentially connected with rheumatism. 
 Now taking true chorea, there is, even in the 
 rheumatic cases, often something more than the 
 constitutional basis of mobility of the nervous sys- 
 tem, influenced and played upon by the rheumatic 
 poison. There is frequently another factor — nervous 
 shock. Sometimes the rheumatic invasion seems to 
 be the direct exciting cause, as well as the predis- 
 posing influence ; when, for instance, as often hap- 
 pens, chorea immediately follows or is concurrent 
 with articular- rheumatism, and endocarditis or peri- 
 carditis; But shock or mental excitement is fre- 
 quently found as the immediate exciting cause of the 
 choreic disturbance in rheumatic subjects. Witness 
 
56 FRIGHT CHOREA 
 
 the case of J. T , Series X., eminently rheumatic, 
 
 yet having two attacks of chorea ascribed to fright 
 long before the first arthritis ; and this shock or 
 excitement is a common exciting canse enongh in 
 rheumatic cases. A remarkable instance of the effect 
 of mental excitement came under my observation a 
 year or two ago in a case of rheumatic chorea. A 
 little girl of eight years old had acute rheumatism, 
 with endocarditis and pericarditis, and followed 
 immediately by severe chorea. The chorea got 
 absolutely well in the course of a few weeks, and the 
 child was brought up to London for change. She 
 was taken to the pantomime for the first time, and 
 became wildly excited. The next morning I was 
 sent for to see her ; chorea had returned so violently 
 that she had to be held by her mother and nurse to 
 keep her falling from the bed. I have never seen 
 more extreme jactitation. This happened instantly 
 in a single night. And, again, a public schoolboy 
 under my care for chorea following articular rheu- 
 matism, on his recovery returned to school and to 
 work. His chorea did not return until he got into 
 a quarrel and scuffle with another boy. The next 
 day he was again choreic as before. I would insist 
 on the fact that there is nothing antagonistic be- 
 tween the agency of nervous shock or excitement and 
 
RELATION OF CHOREA TO RHEUMATISM 57 
 
 rheumatism. They are concerned together as factors 
 in many cases of chorea, as in the two examples just 
 quoted. Yet fright chorea and rheumatic chorea 
 are spoken of as if distinct. If fright is the im- 
 mediate exciting cause in a given case it is labelled 
 'fright chorea,' as distinguished from rheumatic 
 chorea. Such distinction is fallacious and mislead- 
 ing, and has confused the etiology of chorea. The 
 rheumatic state is the most common predisposing 
 cause. Sometimes the choreic disturbance follows 
 on this without obvious immediate exciting cause. 
 Often a nervous shock stirs it suddenly into action ; 
 fright acts equally on rheumatic and non-rheumatic. 
 Turning now to the vexed question of the degree 
 of closeness and constancy of the connection between 
 chorea and rheumatism, I would point out that 
 the only evidence dealt with by most writers on the 
 subject is the occurrence of acute articular rheuma- 
 tism either preceding or accompanying the chorea. 
 But there is a great deal of evidence in addition, 
 some of it of quite recent development, which bears 
 upon the question ; this cannot be ignored ; it must 
 at least be taken into consideration and duly weighed 
 in order to come to a correct judgment in the matter. 
 Let me indicate some of these neglected data. In 
 the first place, it appears from the Statistics of the 
 
58 EVIDENCE FROM INCIDENCE ON THE SEXES 
 
 Collective Investigation Committee, as previously 
 stated, that between the ages of ten and fifteen, 
 girls have a remarkable proclivity to acute articular 
 rheumatism as compared with hoys during the same 
 period, which is that of the maximum incidence 
 of chorea. This corresponds with a similar greater 
 proclivity during that same period of girls as com- 
 pared with boys to organic heart-disease associated 
 with acute rheumatism, to organic heart-disease 
 associated with chorea, and to articular rheumatism 
 associated with chorea. The special proclivity of 
 girls to chorea is more protracted, extending through- ■ 
 out childhood and adolescence. This singular har- 
 mony of relative incidence of these affections upon 
 the sexes is possibly capable of more than one inter- 
 pretation, but it is prima facie very suggestive of a 
 close pathological connection. 1 
 
 Further, there is the evidence of arthritis occur- 
 
 1 Collating the cases given in the Collective Investigation Record, 
 it appears (Tables of Cases, vol. iv.) that, for this period of eleven to 
 fifteen, acute articular rheumatism is met with in girls as compared 
 with boys as 47 to 25, or nearly 2 to 1 ; rheumatic heart-disease in 
 about the same proportion — viz. 28 to 16, or nearly 2 to 1. Chorea 
 associated with antecedent or concurrent articular rheumatism occurs 
 in girls as compared with boys in still higher proportion — viz. 116 to 
 32 (vol. xiv. p. 47), or more than 3 to 1 : organic .heart-disease in 
 connection with chorea (collated from cases in vol. iii.) also in 
 greater proportion— viz. 43 to 13, or more than 3 to 1 ; chorea gene- 
 rally, 131 to 47, or not quite 3 to 1 (vol. iii. p. 47). 
 
OF ARTHRITIS SUBSEQUENT TO CHOREA 59 
 
 ring after the chorea. This is by far the least 
 common sequence. The proportion is not large, yet, 
 according to my observation, much more than 
 indicated by the thirteen instances out of 655 cases 
 of rheumatism furnished by the Collective Investi- 
 gation Record. Of these, nine are under the age 
 of nineteen ; three, twenty-four ; one, twenty-seven. 
 The explanation lies probably, partly in the fact that 
 these cases comprise a singularly small proportion of 
 children. A considerable number of children with 
 rheumatic chorea must be carried off by heart-disease 
 before reaching maturity, and those who survive are 
 forgetful of slight choreas which are usually classed 
 as fidgetiness or nervousness. 1 Be this as it may, 
 however, there are a certain number of cases of 
 chorea connected with rheumatism usually excluded 
 from the estimate. 
 
 Then, again, there is the evidence afforded by the 
 association of chorea with other conditions which 
 are themselves found in close relation to articular 
 rheumatism — i.e. the other members of the rheu- 
 matic series. This evidence is of weight cumulative 
 
 1 That this is so I have many times had proof from private cases 
 — children brought for nervousness and restlessness, who on examin- 
 ation turn out to have the jactitations of slight chorea. These cases 
 do not come into hospital, and amongst the poor they probably never 
 come under the observation of a doctor. 
 
60 EVIDENCE OF OTHEE PHASES 
 
 in proportion to the nuinber and importance of the 
 phases combined. Thus the occurrence of endo- 
 carditis or pericarditis in association with chorea 
 would have a certain significance. When a case 
 of endocarditis or pericarditis arises in connection 
 with chorea, even if there be no arthritis, since 
 rheumatism is the chief cause of endocarditis 
 and pericarditis on the one hand, and so closely 
 associated with chorea, on the other, the concurrence 
 of these — each per se allowed to be frequently 
 rheumatic — affords a considerable presumption that 
 they are together rheumatic. There is no other 
 general morbid state so closely associated with chorea 
 as rheumatism. There are only two diseases largely 
 and closely associated with endocarditis — viz. chorea 
 and rheumatism. Explanations, more or less plau- 
 sible, have been suggested as to the cause of the 
 endocarditis of chorea apart from rheumatism. But no 
 dynamic theory will explain the pericarditis of chorea 
 when it occurs without articular affection. The signi- 
 ficance of this fact has, I think, been overlooked. 
 
 The association of erythema nodosum or tonsillitis 
 with the endocarditis or pericarditis would greatly 
 strengthen the presumption of the rheumatic nature 
 of an accompanying chorea ; while the presence of 
 nodules, so absolutely associated with rheumatic 
 
EVIDENCE OF FAMILY HISTORY 61 
 
 activity, would be in itself, I think, conclusive. The 
 recent recognition of the rheumatic relations of the 
 exudative erythemata and nodules has, indeed, 
 brought much new light, and the evidence which 
 these affections afford has yet to be fully collected 
 and appraised. The history of a strong family pre- 
 disposition to rheumatism, again, would possess a 
 
 certain value. Look at the case of W. S in 
 
 Series VIII., and that of J. T in Series X. In 
 
 both these, as I pointed out previously, the chorea 
 occurred long before the joint affection ; and there 
 was nothing to identify it as rheumatic at the time 
 it occurred except the accompanying endocarditis, 
 and in the latter case the fact that the child's mother 
 had had rheumatic fever ; yet later came the fatal 
 series of events stamping it as rheumatic — the 
 endocarditis, pericarditis, nodules, and arthritis. 
 
 Two days ago I saw a boy of eight (Charles 
 B— — ),* the child of well-to-do people, who had 
 general chorea of moderate intensity. He had never 
 had arthritis, he had no nodules, and there was no 
 sign of cardiac affection. I learnt, however, from 
 the boy's mother, a young woman, that she suffered 
 frequently from painful swelling of the finger-joints ; 
 that her brother, a young man of thirty, suffered 
 1 Notebook XIII. p. 467. 
 
62 EVIDENCE OF FAMILY HISTORY 
 
 from valvular disease of the heart, on account of 
 which he had been refused for life assurance ; that 
 her mother and two of her mother's sisters suffered 
 from subacute rheumatism, and another of her 
 mother's sisters had had rheumatic fever. No 
 neurotic taint of any kind could be made out. Does 
 not such a history afford at least a presumption that 
 the chorea known to be so often rheumatic owed some- 
 thing to the rheumatic connection in this instance ? 
 It is, moreover, to be noted that this history was 
 only elicited by careful cross-examination. The 
 answer to my first question, as to whether there was 
 rheumatism in the family, was in the negative. Had 
 I been content with it I should have failed to trace 
 the rheumatic taint. 
 
 Another case (D. D ) l now under my care is 
 
 more suggestive — a little girl of four, brought to me 
 for a slight general chorea. She had never had 
 articular rheumatism. There were no nodules to be 
 found, and the heart's sounds were normal. On 
 inquiry I learnt that the mother's sister had had 
 rheumatic fever and severe chorea ; her mother had 
 had rheumatic fever, and died of heart disease. 
 Does not such a history raise a strong presumption 
 of the rheumatic connection in the child's chorea ? 
 1 Notebook XIV. p. 7. 
 
EVIDENCE OF STATISTICS 63 
 
 Again, I have this week received into the 
 Children's Hospital a boy of five, with chorea and 
 small nodules. He has no arthritis, apparently no 
 fresh endocarditis. The pulse is quiet ; the tempera- 
 ture normal. The only sign of rheumatic activity 
 is the development of the nodules, and with it the 
 chorea. Yet he had rheumatic arthritis more than 
 ten months ago, and has a double mitral murmur. 
 
 Take, again, the case of H. C , Series IV. 
 
 He had chorea in 1875, accompanied no doubt by 
 endocarditis, for he was admitted with advanced 
 mitral disease in 1878. He had never had arthritis 
 as far as was known. But his mother had had rheu- 
 matic fever and mitral disease. Is it not probable, 
 to say the least of it, that the endocarditis and chorea 
 were both rheumatic, the arthritis possibly having 
 occurred without being noticed, or being yet to follow 
 (as we have seen it sometimes do) later in the series? 
 
 Evidence of this kind must be taken into account, 
 although it is difficult to estimate it statistically. 
 When all these considerations which I have pointed 
 out have been allowed due weight, there remains 
 still a certain proportion of cases in which no rheu- 
 matic connection of any kind can be traced. The 
 unsettled question is as to its measure and degree. 
 Various estimates have been made. The value of 
 
64 FALLACY OF ORDINARY STATISTICS 
 
 such estimation is, to my mind, very doubtful. In 
 most instances the data are very imperfect. We 
 may, I think, for example, at once put aside as in- 
 adequate all statistics based — as nearly the whole of 
 them are — solely upon antecedent attacks of well- 
 marked articular rheumatism, since they take into 
 account only one phase, in severe form, occurring 
 previously or concurrent with the chorea. Such sta- 
 tistics are necessarily defective, because— 1. They 
 omit many slight cases of joint or tendon affection 
 such as those of which I gave examples in the first 
 lecture, conditions constantly unnoticed or forgotten, 
 or, if observed, not regarded as rheumatic. 1 2. They 
 omit all cases in which the joint affection comes 
 after the chorea. 3. They fail to take into account 
 all the evidence afforded by the occurrence and con- 
 currence of subcutaneous nodules, of endocarditis, of 
 
 1 It is significant, in relation to the genuine rheumatic character 
 of so-called growing pains, that a family hist ory of rheumatism is found 
 in 49 per cent, of all ' vague pains,' almost identical with the 52 per 
 cent, in definite acute articular rheumatism, and more than double 
 the percentage found in diseases of all kinds, as stated by Dr. Sturges 
 and Dr. Archibald Garrod — viz. 20 per cent. (Collective Investiga- 
 tion Record, vol. iii. p. 48). The case of Kate B , given in the 
 
 first lecture, illustrates this point also. She was admitted for chorea. 
 No history of articular rheumatism either in the patient or her family 
 could be obtained, and the case was recorded as one of non-rheumatic 
 chorea. Twelve days later she developed slight arthritis, lasting 
 forty-eight hours. Three weeks later still pericarditis appeared, the 
 articular affection and chorea having entirely ceased. 
 
COLLECTIVE INVESTIGATION STATISTICS 65 
 
 pericarditis, of erythema, and of tonsillitis ; so that, 
 unless well-marked articular rheumatism has like- 
 wise occurred before the chorea, these are classed as 
 non-rheumatic. 4. They omit to take into account 
 the evidence afforded by family predisposition. The • 
 latest important statistics, those of the Collective 
 Investigation Committee, likewise necessarily under- 
 estimate the rheumatic element, although in less 
 degree. They do, indeed, take into account not 
 only previous acute articular rheumatism, but also 
 those cases in which it accompanied the chorea or 
 followed it immediately. But by the very nature 
 of the case, being a report on chorea at the time, 
 they do not take into account cases where the joint 
 affection occurs some time afterwards, and apart 
 from the chorea. Many cases, again (slight joint 
 affections, not being identified as rheumatic by the 
 observers), are probably classed as ' vague pains.' 
 Many, again, are no doubt altogether overlooked. 
 Moreover, in these statistics, as in others, the sig- 
 nificance of mitral disease, of erythema, of tonsillitis, 
 and of nodules, alone or in combination, is not esti- 
 mated or admitted into the rheumatic proof; and 
 how little this most important and common piece of 
 evidence, the evolution of nodules, is looked for and 
 recognised, and how wanting these statistics must 
 
 F 
 
66 PROPORTION OF RHEUMATIC CHOREA 
 
 be in this respect, appears from the fact that, of 
 439 cases of chorea recorded, in only seven instances 
 were nodules observed. Why, we have sometimes 
 as many in the wards at Great Ormond Street at the 
 same time ! There are six at the present moment. 
 The statistics of the Collective Investigation Com- 
 mittee, based upon this single rheumatic event of 
 articular affection before, during, or immediately 
 after the event, give a 32 percentage of chorea posi- 
 tively rheumatic. If to these be added the cases of 
 vague pains the percentage is 46*2. The estimates 
 of two of the most sagacious clinical observers of 
 our time come near to this. Dr. Stephen Mackenzie 
 found 44-76 per cent, almost certainly rheumatic, 
 and, for reasons similar to those I have put forward, 
 he regards this as representing very imperfectly the 
 rheumatic connection of chorea. Dr. Barlow finds 
 in forty-four out of seventy-three, or 60 per cent., 
 sufficient evidence of rheumatism, and points out that 
 the existence of progressive heart-disease and the 
 imperfection of the record render it probable that 
 many other cases should be included. In eighty- 
 four cases minutely recorded and specially investi- 
 gated by myself, I find satisfactory evidence of acute 
 rheumatism in the patient or immediate relatives 
 in sixty-two — i.e. in 75 per cent. Leaving out the 
 
NERVOUS EXCITABILITY IN RHEUMATISM 67 
 
 family history, the estimate would coincide very 
 closely with that of Dr. Barlow. It may, then, I 
 think, be concluded that in the majority of cases at 
 least chorea is a phase of rheumatism. 
 
 It is not my purpose to enter into the question of 
 the minute morbid anatomy of chorea, or the exact 
 mechanism by which the motor disturbance is effected 
 — whether by embolism in the motor tract, or by 
 thrombosis there, or the irritant effect of the rheu- 
 matic virus, or the mysterious influence of nervous 
 shock. All these in the present state of precise 
 pathological knowledge can only be matters of specu- 
 lation. But I may point to the possibility of some 
 proliferative change in the neuroglia akin to that of 
 the fibrous tissues elsewhere as a point which needs 
 examination. 
 
 Before leaving the subject of chorea, however, I 
 should like to call attention to the relation of nervous 
 excitability' to rheumatism. The rheumatic children 
 who develop chorea are intellectual, highly strung, 
 excitable, and nervous, often emotional, just as other 
 choreic children. The question arises, is the nervous 
 instability due to the influence of the recent active 
 rheumatic state induced by it ? The extraordinary 
 emotional attacks observed in some cases of rheu- 
 matic chorea (as in the examples of W. S , 
 
 F 2 
 
68 SUBCUTANEOUS TENDINOUS NODULES 
 
 Series VIII., and J. T , Series X.) would favour 
 
 this. Or is the nervous instability part of the original 
 constitution of the child, and chorea produced when 
 this is acted upon by a second factor — viz. rheu- 
 matism ? Or do the two tendencies run together in 
 the original diathesis ? — the child with a tendency to 
 rheumatism inheriting therewith a mobile nervous 
 system, as suggested by Sir Dyce Duckworth. 1 I 
 am inclined to think the latter : that nervous excit- 
 ability goes with the rheumatic diathesis, and that 
 it is stirred up to active eruption of motor disturb- 
 ance in chorea by some direct exciting cause — fright, 
 or acute rheumatism, or pregnancy. I have seen this 
 excitable tendency in the single child of a family in 
 many instances. The rheumatic child is the excit- 
 able, emotional child. The rheumatic tendency and 
 the nervous excitability run together in the same 
 inherited constitution or diathesis. 
 
 Subcutaneous Tendinous Nodules. — I now turn to 
 the next phase or manifestation — viz. the evolution 
 of subcutaneous nodules. The actual discovery of 
 these nodules is no new thing. They were observed 
 by flillier, who gives an excellent account of a 
 typical case in his book on the Diseases of Children, 
 
 1 Address to the Thames Valley Branch of the British Medical 
 Association at Richmond (Brit. Med. Jour. Jan. 3, 1885). 
 
THEIR FREQUENCY 69 
 
 published in 1868. The case was one of chorea with 
 pyrexia and organic mitral murmur, but no articular 
 rheumatism. Cases have since been reported by 
 Meynet and others. I had long been familiar with 
 them as occurring occasionally in the course of 
 articular rheumatism; but the credit of pointiug 
 out their frequency and great importance as clinical 
 signs in. the various manifestations of rheumatism 
 belongs to Dr. Barlow and Dr. Warner. 1 These 
 fibrous nodules are common in children — much more 
 rare in adults. I have seen only two cases in adults, 
 scores in children. This is perhaps partly the reason 
 why they have not been more frequently observed, 
 for we take our ideas of rheumatism from the disease 
 as seen in adults. A second reason why they are not 
 observed is that they are not known or looked for ; 
 and a third reason why they often escape notice is 
 their small size in many cases. They are sometimes 
 to be felt rather than seen. In one case now under 
 my observation, two of these growths, the size of a 
 hempseed, on the tendons of the outer malleolus, 
 only become visible when the skin is drawn tightly 
 over them, although they can be detected readily 
 enough by touch. In < the 655. cases of articular 
 
 1 Trans. Int. Med. Cong. 1881, vol. iv. 
 
70 CHARACTERS OF NODULES 
 
 rheumatism given in the Collective Investigation 
 Record (vol. iv.), there are only thirty-six in which 
 nodules are recorded. Of these only- five are in 
 children under sixteen ; but then the returns embrace 
 a very small proportion of children. The chorea 
 returns 1 yield only twelve cases out of 439. Yet 
 I have at the present moment five under my care 
 in hospital, and there are two more under my col- 
 leagues ; all these are, except one of articular rheu- 
 matism, cases of chorea. The nodules vary in size, 
 from that of a hempseed to that of an almond or 
 larger; in extreme instances they may attain that 
 
 of half a walnut, as in the case of W. S , Series 
 
 VIII. (represented in the coloured illustration), and 
 
 also in that of J. T , Series X., and some others. 
 
 The nodules lie under the skin, and are connected 
 with fascia or tendons — in relation with fibrous 
 tissues. They are not tender, except slightly in rare 
 instances. There is no redness of the skin over 
 them, except occasionally from friction or pressure. 
 They are found most commonly upon the back of 
 the elbow, over the malleoli, and at the margin of 
 the patella. They are also found not uufrequently 
 upon the head, especially along the superior curved 
 line of the occiput, the temporal ridge, and now and 
 
 1 Coll. Invest. Record, vol. iii. 
 
THEIR DISTRIBUTION AND DURATION 71 
 
 again upon the extensor and flexor surfaces of the 
 hands, on the extensors of the feet, the vertebral 
 spines, the spine of the scapula, and the crista ilii. 
 
 In extreme cases — as in that of W. S- , nodules 
 
 may be found in nearly all these positions. Once 
 I have seen them the size of almonds studded over 
 the flexor tendons on the palms of the hands, and 
 once in great numbers over the tendinous structures 
 of the intercostals, on the front and sides of the 
 thorax. There may be only one of these nodules, 
 but more usually three or four are to be found; 
 sometimes the number is large, as many as thirty or 
 forty.. I have counted thirty-five at one time. Some- 
 times there is only a single crop ; sometimes several 
 crops appear in succession. These fibrous growths 
 are developed to perceptible size in the course of a 
 few days ; I have, for example, been unable to find 
 one anywhere at one hospital visit, and have dis- 
 covered several at the next, three days later. The 
 large nodules, however, take a considerable period 
 to attain their full dimensions. Their duration varies 
 from a few days. to several months. The shortest 
 time I have noted is fourteen days, but Dr. Barlow l 
 observed one to come and disappear again in three 
 days. Large nodules — such as those of W. S 
 
 1 Trans. Int. Med. Cong. 18S1, vol. iv. 
 
72 STRUCTURE OF TENDINOUS NODULES 
 
 shown in the Plate — have an existence of months. 
 Dr. Barlow has recorded their persistence for five 
 months. The evolution of the nodules in itself 
 gives rise to no pain or fever. If this be present, 
 it is due to concurrent arthritis, or cardiac inflam- 
 mation, or pleurisy. For example, in the case of 
 two children under my care, in whom nodules have 
 developed in conjunction with chorea, the tempera- 
 ture has never been above normal. When the 
 nodular growths are exposed by dissection, they 
 appear as c oval semi-transparent fibrous bodies, like 
 boiled sago-grains.' l Examined microscopically in 
 thin section, they exhibit wavy bands of tissue, 
 with caudate and spindle-shaped cells and abundant 
 nuclear growth, and they are highly vascular. 
 They consist, therefore, of nuclear growth in pro- 
 cess of devekrpnient into fibrous tissue in all stages 
 of transformation. These appearances are shown 
 in the section under the microscope, for which I 
 am indebted to Mr. Priestley, the registrar to 
 the Children's Hospital, and are represented in the 
 drawings given in the next lecture. A subcutaneous 
 nodule is a proliferation of fibrous tissue, just such 
 as that developed in the interstitial framework of 
 the liver or in the nerve-sheaths by undue stimulation 
 
 1 Tram. Int. Med. Cong. 1881, vol. iv. 
 
CONNECTION OF NODULES WITH RHEUMATISM 73 
 
 of alcoholic or other irritation. As Dr. Dickinson 
 has well said, 1 the tissues of a child, and especially 
 the fibrous tissues, are more readily excited to sprout 
 in this way than those of adults, as shown by the 
 rapid growth of fibrous tissue in hypertrophic cir- 
 rhosis and interstitial nephritis in children ; the quick 
 hypertrophy of muscle in cardiac disease and the 
 marvellous growth of sarcomatous tumours are ana- 
 logous examples. On this point I shall have more 
 to say in the next lecture, when I come to speak 
 of endocarditis and pericarditis. 
 
 The connection of these nodules with rheumatism 
 is extremely close, and I believe absolute. As far as 
 I can judge, they own no other origin or connection. 
 In all cases in which I have seen them, there has 
 been either rheumatic joint affection at the time or 
 at some period of the child's history, or such a con- 
 currence of rheumatic events, one or more — such as 
 endocarditis, pericarditis, chorea, and erythema — 
 that there could be no doubt as to the nature of the 
 condition. In nineteen out of twenty-seven cases 
 recorded by Dr. Barlow there was arthritis ; in six 
 more there was distinct joint pain, and other evi- 
 dence of the rheumatic state. In nearly every case 
 
 1 Introductory Address at the Hospital for Sick Children 
 {Lancet, November 3, 1888). 
 
74 EVIDENCE OF THE RHEUMATIC RELATION. 
 
 recorded by others, the rheumatic connection has 
 been clearly traced. As evidence of rheumatism they 
 are, I think, indisputable. But there is something 
 more than this. Not only are these nodules con- 
 nected with rheumatism, but they are specially con- 
 nected with the graver forms of it ; and they are 
 signs, serious apparently in proportion to their size 
 
 and number. Look at the case of W. S (Series 
 
 VIII.) and that of J. T (Series X.) What a list 
 
 of rheumatic events ! In the first, . repeated endo- 
 carditis, chorea, arthritis, and almost certainly peri- 
 carditis, accompanied the evolution of nodules. In 
 the second, endocarditis, chorea, pleurisy, and peri- 
 carditis. Both cases ended fatally in spite of all 
 treatment. Nothing availed to stop steadily pro- 
 gressive endocarditis and pericarditis. Salicylate of 
 soda, salicin, free doses of alkalies and quinine, and 
 mercurial inunction were equally futile. Of six cases 
 of this kind, where the nodules were numerous and 
 large, which came under my care at the Children's 
 Hospital during the last year, four were fatal. In all 
 cases but one there was chorea. In every one there 
 was endocarditis. In three, and probably in four, 
 there was pericarditis. In two there was pleurisy. 
 
 So far as my present experience goes, I regard 
 the eruption of large nodules, such as are shown 
 
CLINTCAL SIGNIFICANCE OF NODULES 75 
 
 in the Plate, as almost equivalent to a sentence of 
 death. They mean persistent cardiac disease, gene- 
 rally uncontrollable, and marching almost infallibly 
 to a fatal ending. General experience agrees as to 
 the grave significance of these fibrous growths, which 
 were at first looked upon as unimportant curiosities. 
 Seven years ago, Dr. Barlow and Dr. Warner 1 re- 
 cognised their serious import. In every one of the 
 twenty-seven cases observed by them there was or- 
 ganic heart-disease; in eight there was pericarditis; 
 in twelve there was progressive valvular disease ; and 
 eight were fatal in spite of all treatment. The fore- 
 cast has proved correct. Dr. Money, who has since 
 investigated the subject, found nodules in half the 
 cases of rheumatism in which well-marked heart- 
 disease occurred, and my experience is quite in 
 accord with these observations. The cases recorded 
 by others appear to have been almost uniformly 
 severe and frequently fatal. I could give examples 
 of the association of these nodules with every other 
 phase of the rheumatic series, as well as with endo- 
 carditis and pericarditis and chorea and pleurisy 
 already mentioned; and in all these cases the evi- 
 dence they afford as to the rheuma/fcic nature of the 
 affection is of the highest value, and I believe 
 1 Trans. Int. Med. Cong. 1881, vol. iv. 
 
76 PLEURISY EITHER PRIMARY OR SECONDARY 
 
 decisive. But their greatest interest lies in the fact 
 of their frequent association with endocarditis and 
 pericarditis of the most deadly, although subacute 
 form, and in their connection with chorea. 
 
 Pleurisy. — Pleurisy occurs in association with 
 rheumatism in two distinct ways. It arises fre- 
 quently towards the end of rheumatic heart-disease 
 — partly, perhaps, as a result of the mechanical con- 
 gestion of the pleura, caused by the valvular defect, 
 or by pericarditis, or by extension from the latter. Of 
 this late pleurisy, instances are common enough, as 
 in the cases of Series II. and X. Of it I shall say 
 nothing further, since it is probably due as much to 
 cardiac as to primary rheumatic causes. But pleurisy 
 likewise occurs in rheumatism as an initial pheno- 
 menon, coming immediately before, together with, 
 or immediately after arthritis, as a direct result of 
 rheumatic influence. It is likely enough that it 
 occurs quite independently, apart from all other 
 phases, yet still a rheumatic manifestation. Pro- 
 bably many of the simple pleurisies and pleuro- 
 pneumonias we see and regard as idiopathic would 
 be found, on careful inquiry, to be of rheumatic 
 origin. This is a point which deserves further 
 investigation. Cases such as the two following 
 are, however, very suggestive. For the particulars of 
 
PRIMARY RHEUMATIC PLEURISY 77 
 
 the first I am indebted to Dr. Lewis, of Hamilton 
 Terrace, with whom I saw the case. 
 
 On Dec. 22nd, 1887, a boy of ten travelled tip to 
 town from the seaside in extremely bitter weather. 
 On the 24th he complained of pain in the ear, and 
 subsequently had purulent discharge from it. On 
 the 25th he was sick twice. At this point Dr. Lewis 
 saw the boy, and found him with a temperature of 
 104°, and sweating profusely. No physical signs of 
 any kind could be detected. On the 26th the fever 
 and sweating continued ; the temperature was 104* 2°. 
 On examination of the chest, pleuritic friction was 
 heard at one spot, and this had greatly extended 
 next day. Three days later he complained of pain 
 and stiffness in the wrists, knees, and ankles, which 
 were discovered to be swollen and tender. Signs of 
 pneumonia had also developed. Salicin was given 
 freely, and in forty-eight hours the articular symp- 
 toms subsided. The next day the temperature came 
 down rapidly, and there was considerable collapse, 
 which passed off, and the boy got quickly well. 
 The heart remained unaffected. 
 
 The second case is that of a boy now under my 
 care at St. Mary's. 1 He was admitted with signs of 
 some consolidation and pleuritic effusion on the left 
 F. a. H- , Albert ward, December 1888. 
 
78 .ETIOLOGY OF RHEUMATIC PLEURISY 
 
 side, and cough. Three days later both wrists and 
 knees became stiff, tender, and swollen ; the tem- 
 perature was 103°. Under salicin the arthritis 
 quickly subsided, and the boy made a quick and 
 rapid recovery. 
 
 It may be that in such cases the pleurisy is 
 simply the direct result of chill, just as the articular 
 rheumatism is the result of chill, both being due to 
 a common cause. Yet, pleurisy comes sufficiently 
 often later still in the course of acute articular 
 rheumatism, when it can hardly be attributed to the 
 initial chill, and when there is no serious cardiac 
 change to account for its origin in mechanical con- 
 gestion, to render its immediate dependence upon 
 the rheumatic virus highly probable. 
 
LECTUEE III. 
 
 Pericarditis— Its connection with other phases of rheumatism- 
 Special characteristics in childhood— Subacute, recurrent, dry- 
 Tendency to fibrosis and chronic thickening rather than to effusion 
 —Endocarditis; subacute and recurrent likewise— Special lia- 
 bility of children and of young girls— Connection of endocarditis 
 with other phases of rheumatism— The endocarditis of chorea— 
 Eelation of pericarditis and endocarditis to the evolution of 
 nodules— Morbid changes in nodules and cardiac valves ana- 
 logous—Significance of this— Different forms of valvular disease 
 —Mitral stenosis— Early signs— Double second sound at the apex 
 ' —Hypertrophy and dilatation— Comparative rarity of dropsy— 
 The mode of death differs from that met with in adults— Scar- 
 latinal rheumatism— Eheumatoid arthritis— Special points in 
 treatment. 
 
 Pericarditis is admitted into the rheumatic series 
 without question. It is, I think, undisputed that 
 inflammation of the pericardium owns rheumatism as 
 its most common cause. Pericarditis may appear at 
 any point in the rheumatic procession of events — first 
 or last, alone or in combination with other phases. 
 Most often it comes late, after endocarditis, especially 
 when the heart is already hypertrophied and dilated. 
 Sometimes it is associated with the valvular inflam- 
 
80 PERICARDITIS 
 
 ination, is often accompanied by the evolution of 
 nodules, and not unfrequently arises in connection 
 •with chorea. The development of pericarditis in 
 association with chorea apart from articular rheuma- 
 tism is a link of association between them which is 
 of considerable significance. Examples of different 
 combinations and the place of pericarditis are shown 
 in the illustrative cases, especially in Series II., VI., 
 
 and X., and in the case of Kate B given in the 
 
 first lecture, as well as in some examples which I am 
 about to put before you. But the pericarditis with 
 which we are most familiar — the acute general peri- 
 carditis of rheumatic fever — is not representative 
 of the disease in children. The extreme distress ; the 
 panting, shallow respiration ; the fluttering, irregular 
 pulse ; the strange delirium ; the physical signs of 
 friction all over the cardiac area as lymph is poured 
 out; the extensive dulness, often following quickly 
 as serous effusion takes place, spreading high up to 
 the second or third rib ; the muffled heart's sounds ; 
 the raised apex — all these classical signs are some- 
 times wanting, at other times largely modified, in the 
 rheumatic pericarditis of childhood in its most usual 
 form. 
 
 Such cases of acute general pericarditis do occur 
 in the acute rheumatism of childhood, as well as in 
 
THE ACUTE FORM 81 
 
 adults, but they form the exception. I have just had 
 under my care at St. Mary's a girl of seven, Elizabeth 
 
 S , l who developed most acute pericarditis with 
 
 chorea, and died of it in ten days. There was not the 
 slightest accompanying articular affection, not the 
 smallest joint pain or tenderness ; the temperature 
 ranged between 98° and 100° only except for one 
 night, when it reached 101-5° ; but— most evil sign — 
 the pulse ran up to 130 and 140. The child had had 
 slight articular rheumatism seven months previously, 
 and again a fortnight before admission and prior to 
 the chorea. Her father had had rheumatic fever ; 
 her sister aged twelve, subacute rheumatism. There 
 was a rumbling mitral murmur. The child was thin, 
 pallid, and feeble. The progress of ansemia since 
 the advent of pericarditis was most remarkable ; in 
 the last few days of life it became extreme. More- 
 over — what I will ask you to mark especially — there 
 were no nodules, so common an accompaniment of 
 cardiac inflammation in a child, whether it be 
 endocardial or pericardial, as I pointed out before. 
 This very acute inflammation appears to be less 
 identified with the development of nodules than the 
 more chronic form. 
 
 Let me give another example of intensely acute 
 
 1 Children's ward, December 1888. 
 
 G 
 
82 EXAMPLES OF ACUTE PERICARDITIS 
 
 general pericarditis, associated with equally extreme 
 
 chorea, probably rheumatic. M. B , a girl of 
 
 fifteen, was admitted under my care at . St. Mary's 
 Hospital in August, 1885, with chorea of trie, most 
 violent kind, rapid respiration and panting dyspnoea. 
 She had been ill about three weeks, but it was im- 
 possible to obtain any clear history, for the people 
 who brought the patient could give us little infor- 
 mation about her, and the girl herself was unable to 
 utter a word. She made frantic attempts to speak, 
 but could not articulate, uttering only unintelligible 
 sounds. The jactitations were so violent that she 
 had to be fastened down in bed, and it was not 
 possible to examine the chest satisfactorily, so con- 
 stant and uncontrollable were the movements. By 
 the aid of two nurses I was just able to make out 
 that the area of cardiac dulness was increased, the 
 heart's sounds — as, indeed, extreme feebleness of the 
 pulse showed — were almost inaudible, and a faint 
 friction-sound could be detected at one point. The 
 diagnosis was rheumatic chorea and pericarditis with 
 some effusion. Before evening, a few hours after 
 admission, the patient died. On post-mortem exa- 
 mination, extensive pericarditis was found, the peri- 
 cardial sac being greatly distended with turbid, 
 flaky, sero-purulent fluid, and the surfaces thinly 
 
SUBACUTE PROGRESSIVE PERICARDITIS 83 
 
 coated with recent ljrnph. There was also inflam- 
 matory thickening of the mitral valve. In this in- 
 stance, the chorea, endocarditis, and pericarditis 
 occurring in the same individual stamped the case as 
 almost certainly rheumatic. 
 
 Now, instances of extremely acute pericardial in- 
 flammation like these occur as they do in adults. But 
 this is not the most frequent and typical form of 
 pericarditis in children. It usually occurs insidiously ;. 
 a slight pericardial rub is noted perhaps, which may 
 cease or continue without much change; the child is 
 seen to be restless and uncomfortable, and complains 
 of pain in the precordial region ; the pulse quickens 
 to 120 or 130; the ansemia increases to a marked 
 degree ; the chorea, if present, becomes a little 
 aggravated perhaps, or curious emotional attacks 
 come on, the child being moved to tears or laughter 
 by a word; the temperature is slightly raised, 
 perhaps to 100° or 101°, but often remains normal 
 if there is no accompanying arthritis, or pleurisy, or 
 pneumonia ; and with this a mitral murmur develops, 
 or an existing one grows rougher, and subcutaneous 
 nodules begin to appear on the elbows and knees, or 
 ankles or occiput. The pericardial rub continues, or 
 subsides after a few days, to reappear again after an 
 
 G 2 
 
84 THE TYPICAL FORM IN CHILDHOOD 
 
 interval perhaps, or, although it never reappears, 
 the rapid action of the heart continues, iu spite of 
 digitalis, or belladonna, or strophanthus, or ergot; 
 fresh nodules come out ; the area of cardiac dulness 
 increases,' and there is muffling of the sounds over 
 the mid-cardiac region, but no sign of effusion ; the 
 heart is clearly growing more bulky and the peri- 
 cardium thicker, and emaciation and ansemia pro- 
 ceed apace. The child daily grows more pallid, 
 weak, and wasted ; the pulse grows more feeble ; and 
 so, without extreme dyspnoea or dropsy, the patient 
 sinks slowly from exhaustion and he art- failure. 
 
 Such, gentlemen, is a picture of the pericarditis 
 of childhood in its most usual form, so frequently 
 associated with the evolution of subcutaneous nodules, 
 often with endocarditis, and often with chorea. It 
 
 represents very closely the case of J. T , Series 
 
 X. And mark what is found after death : usually 
 the two surfaces of the pericardium glued together 
 by a thick layer of adhesive lymph ; the pericardium 
 itself greatly thickened ; the walls of the sac tough, 
 dense, fibrous tissue, an eighth of an inch thick, 
 perhaps ; the chronic inflammatory process spreading 
 sometimes from the external sac to the anterior 
 mediastinum, so that these are matted together in a 
 thick fibrous mass — ' indurative mediastino-pericar- 
 
SUBACUTE PROGEESSIVE PERICARDITIS 85 
 
 ditis/ as seen in the specimen from one of these 
 cases now before you. 
 
 Take, again, the case of C. H. B (Series II.), 
 
 a boy of six, who was admitted to the Hospital for 
 Sick Children on May 8, 1888. The boy had never 
 complained of anything until five weeks before, 
 when he had stiffness in that typical place which 
 I mentioned in the first lecture — viz. the hamstring 
 tendons — and in the ankles ; but they were not 
 noticed to be swollen or tender. Then he had pains 
 in the shoulders, and then in the chest, for which he 
 was poulticed ; but he was never kept in bed, nor 
 was it thought necessary for a doctor to see him, 
 although he was observed to be very breathless on 
 exertion. The pains were supposed to be growing 
 pains merely; rheumatism was not thought of. 
 Latterly he had grown very excitable and nervous, 
 and had twitching of the limbs. On examination, he 
 was found to have a double mitral murmur with a 
 highly accentuated second sound, and considerable 
 hypertrophy; the dulness reached to the left edge 
 of the sternum, and upwards as high as the third 
 rib ; the apex-beat was in the fifth space, three- 
 quarters of an inch outside the left nipple — so that 
 the valve disease must have been of considerable 
 standing, due to endocarditis of much earlier date 
 
8G SUBACUTE PROGRESSIVE PERICARDITIS 
 
 than the late articular pains. There was also dis- 
 covered a crop of fibrous nodules on the elbows, knees, 
 and malleoli, so small as not to attract attention 
 unless carefully looked for. The boy was extremely 
 anserine; the pulse suspiciously rapid (124). By the 
 end of the month these nodules had attained con- 
 siderable size, and on June 9th a fresh development 
 of still larger nodules took place on the back of the 
 head, the malleoli, and the knees ; with this, peri- 
 cardial friction occurred two days later, and great 
 pain in the cardiac region, relieved by poultice. In 
 a week's time all pericardial friction had disappeared, 
 but the boy remained pale and anxious, the pulse 
 was quick and irregular, pleuritic friction was heard 
 at the base of both lungs, and the systolic mitral 
 bruit had become musical. A month later (July 14th) 
 a third crop of nodules of large size appeared on the 
 knees and elbows. The cardiac excitement continued, 
 the pulse ranging from 130 to 140 ; pain in the chest 
 came on ; emaciation and anaemia were progressive. 
 No friction could be heard, but the increasing area 
 of cardiac dulness, the rapidity of pulse, which 
 neither digitalis nor any other drug could control, 
 showed no diminution; and thus, in spite of all 
 treatment, the boy went from bad to worse, and died 
 from heart- failure on September 6, just four months 
 
ASSOCIATION WITH SUBCUTANEOUS NODULES 87 
 
 after admission. It is to be noted how in this case 
 the grave symptoms proceeded pari passu with the 
 eruption of large nodules, rapid pulse, progressive 
 anaemia and emaciation, and how steadily and resist- 
 lessly the disease marched on in this way to a fatal 
 end, uncontrolled by any remedial agent. 
 
 Take again another case, that of Arthur C , 
 
 a boy of eleven, who is now under my care at Great 
 Ormond Street Hospital. He came into hospital 
 first in September 1888, with subacute arthritis, 
 great anaemia, a loud double mitral murmur, and 
 great hypertrophy. He quickly went out convales- 
 cent, but was brought back on ^November 12th, again 
 failing in health. On the 22nd the temperature, 
 which had been normal, rose to 101, and well- 
 marked double tonsillitis followed. This was over in 
 three days, and the temperature fell to normal ; but 
 a week later (November 28) he became restless, his 
 respirations went up to 32 and his pulse to 112, he 
 had headache, and vomited. The following day 
 (the 29th) the first sign of nodules was detected on 
 the knees and elbows. The heart's action became 
 more excited ; by December 6 it was violent, and the 
 anaemia had greatly increased; the nodules had 
 grown larger, some to the size of small peas, and a 
 pericardial friction- sound was audible. The tempera- 
 
88 SIGNIFICANCE OF NODULES IN PERICARDITIS 
 
 ture has fallen since to normal, but the pulse keeps 
 between 100 and 112, and there has been dyspnoea at 
 times. The friction continues, the anaemia increases, 
 and the prognosis is most grave. Note here, again, 
 the rapid pulse, the increasing anaemia, and the 
 development of nodules concurrently with the deve- 
 lopment of progressive intractable pericarditis. 1 
 
 Eheumatic pericarditis, then, in early life is apt 
 to be subacute, persistent, recurrent, and progressive ; 
 going on, not for days only, but for weeks or months ; 
 the inflamed membrane slowly or intermittently 
 exuding, not serum, but adhesive lymph, causing 
 adhesions more or less complete, and development 
 of fibrous tissue, so that the pericardium becomes 
 thickened, sometimes enormously, as you see in the 
 specimen produced. This form of subacute pro- 
 gressive pericarditis might almost be called ' nodular,' 
 so frequent is the evolution of these significant 
 bodies associated with it. Their eruption appears to 
 have a deep meaning ; when they are numerous and 
 large, they indicate a condition so grave, and appa- 
 rently often so uncontrollable, that, as I said before, 
 
 1 This unfavourable prognosis has since been verified. The peri- 
 carditis continued in spite of treatment, anaemia and dyspnoea 
 increased, and the boy died about six weeks later. Post-mortem 
 examination revealed general dry pericarditis, with great thickening' 
 and nearly comolete adhesion. 
 
RELATION TO PERICARDIAL FIBROSIS 89 
 
 I have come to regard tliem as almost a sentence of 
 death. 
 
 What is the pathological relation of the fibrous 
 nodule to the fibrosis of the pericardium ? It would 
 seem as if the same virus or influence which stirs up 
 the inflammatory change in the fibrous tissues of 
 sheaths and tendons, and which results in the forma- 
 tion of nodules, stirs up in the same way fibrous 
 organisation of lymph or proliferation of the fibrous 
 tissue of the pericardium. Dr. Barlow found in one 
 case that the pericardial adhesions had a distinctly 
 nodular character ; l and Dr. Angel Money, 2 in a 
 similar case, with extreme pericardial adhesion, found 
 a distinct nodule extending from the pericardium 
 inwards, and invading the heart's substance. I 
 believe that the fatal issue is largely dependent upon 
 the tightening grip of the adherent contracting 
 thickened pericardium, strangling, as it were, the 
 muscle and muscular movements of an often already 
 crippled heart; possibly also the heart-muscle is 
 weakened by fibrous interstitial invasion and by 
 concurrent myocarditis ; hence the rapid pulse and 
 the progressive feebleness of cardiac action. The 
 effect of the continued constriction of the heart by 
 the tough, thickened pericardial casing in early life 
 
 1 Brit. Med. Jour. September 15, 1883, p. 511. 2 Ibid. 
 
90 EFFECT OF THICKENED PERICARDIUM 
 
 upon the due growth of the heart itself was first 
 brought home to my mind some years ago by the 
 following remarkable case. 
 
 A girl, aged nineteen, was admitted into St. 
 Mary's Hospital with general dropsy, for which no 
 satisfactory cause could be made out. She had no 
 signs of either cardiac or renal disease, but she had 
 considerable ascites and hydrothorax, for which she 
 was repeatedly tapped. At last she died. On post- 
 mortem examination, the heart was found tightly 
 enclosed in a bag of dense unyielding fibrous tissue, 
 the adherent pericardium enormously thickened ; 
 the heart itself was as small as that of a child of 
 ten years old ; there was no other lesion of any kind. 
 There could be no doubt that the girl had had 
 fibrous pericarditis as a child, and the embarrassed 
 heart, tightly embraced by the contracting tissue, 
 could not grow ; at length, becoming unequal to carry 
 on the circulation of the enlarging vascular system, 
 dropsy followed. Sir T. Watson 1 observed a similar 
 result. He says : c When the adhesion takes place 
 during youth, as in connection with acute rheumatism 
 it is very apt to do, it seems to prevent the further 
 growth of the heart, and virtually leads to atrophy 
 of that organ or a disproportionate smallness of its 
 
 1 Principles and Practice of Physic, -ith ed. vol. ii. p. 301. 
 
ENDOCARDITIS 91 
 
 cavities, vessels, and general size ' ; and Bouillaud 
 mentions the case of a woman, aged sixty-one, whose 
 heart was the size of that of a child's of ten or twelve, 
 and marked by furrows and opaque spots from old peri- 
 carditis. 1 Usually, however, in the case of children, 
 the pericarditis persists or recurs, or it comes late, 
 when the heart is already dilated and hypertrophied 
 from valvular disease, and the new clog, the tighten- 
 ing grip of the pericardium, is more deadly than it 
 would be to the normal organ. The heart is not 
 small, but enlarged, and although one may believe 
 that its further development might be interfered 
 with, yet death usually takes place before the dis- 
 proportion between heart-growth and the develop- 
 ment of the rest of the body has become conspicuous 
 or extreme. 
 
 Endocarditis. — Endocarditis occurs acutely in the 
 course of articular rheumatism in children, just as 
 it does in adults. The position of endocarditis as 
 one of the rheumatic inflammations is like that of 
 pericarditis, established and allowed. Yet in child- 
 hood it often occurs quite apart from any concurrent 
 affection of the joints ; and it may develop at any 
 period in the rheumatic procession of events, early 
 
 1 Payne's, Jones', and Sieveking's Pathological Anatomy, 2nd 
 ed. p. 341. 
 
92 CHARACTERS OF ENDOCARDITIS IN CHILDHOOD 
 
 or late, in combination with arthritis or pericarditis, 
 or chorea, or nodules, with any or all of these 
 combined. Usually it comes early in the series, and 
 recurs later, in contrast to pericarditis, which is 
 more apt to appear towards the end. An example 
 of this is given in Series II., where it came first. 
 The rule is : endocarditis early ; pericarditis late. 
 But as with pericarditis, so with endocarditis ; the 
 acute form in connection with severe articular rheu- 
 matism is far less common than one slight and trivial 
 apparently at the time, accompanying an equally 
 slight articular affection or chorea ; all sign of it 
 perhaps disappearing for a season, yet recurring and 
 persisting until the injury to the valve becomes 
 serious and finally fatal. It is not, as it is so com- 
 monly with adults, a sharp attack of endocarditis 
 accompanying the articular affection, ceasing with it, 
 and followed slowly by chronic after-changes in the 
 valve or muscle ; but subacute, insidious, progressive. 
 In the first lecture I endeavoured to show how 
 an extremely slight and transient arthritis, hardly 
 noticeable, not recognised as rheumatic, probably 
 not coming under a doctor's observation at all, might 
 be accompanied by valvulitis, running on unsuspected 
 at the time, and only discovered afterwards when 
 great cardiac changes have developed. Dr. Sibson, 
 
RELATION OF ENDOCARDITIS TO RHEUMATISM 93 
 
 whose name will always be honoured in this Society, 
 affirmed that the more severe the rheumatic attack, 
 the greater the tendency to cardiac inflammation. 
 Probably this is so. Severe attacks of articular rheu- 
 matism are, however, rare in young children; and, 
 light as the arthritis usually is, children are nearly 
 twice as liable to cardiac inflammation as adults. 1 
 
 Valvular disease of the heart in childhood is 
 not invariably the result of rheumatic endocarditis. 
 There are certain exceptions.' We may exclude the 
 cases of congenital disease and those where the en- 
 docarditis is set up by one of the specific fevers, or 
 the septic or ureemic poison. There will remain for 
 consideration three classes — viz. (1) those cases in 
 which the valvular affection arises in association with 
 distinct attacks of articular rheumatism ; (2) those 
 associated with chorea in which no articular affection 
 is observed; and (3) those in which no connection 
 with any other morbid condition of any kind can be 
 traced — what may be called the ' unexplained cases/ 
 
 Now, with regard to the first class, cases of heart 
 affection connected with articular rheumatism, the 
 organic change would, I think, be generally allowed 
 to be due to rheumatic endocarditis. And these 
 
 1 Collective Investigation Record, vol. iv. p. 71. 
 
94 STATISTICS 
 
 form the largest proportion. Dr. West 1 gives 
 statistics of 135 cases of organic valvular disease, of 
 •which, in 60 per cent, rheumatism was i either known 
 or asserted on good grounds to have been the start- 
 ing point of the mischief ' ; and he quotes the esti- 
 mate of M. Roger as 78 per cent., and that of M. 
 Cadet de Gassicourt as 81 per cent. Dr. Goodhart's 
 statistics yield 62 per cent. 2 My own statistics of 
 195 cases specially examined and investigated for 
 the purpose, including the evidence of rheumatic 
 fever in parents or immediate blood-relatives, give 79 
 per cent. 3 All these are based upon the occurrence 
 of articular rheumatism only, and the absence of 
 evidence of this in any given case is not to be taken 
 as positive proof of its non-rheumatic nature. 
 
 The only question which arises, then, is with re- 
 gard to the two remaining groups, those associated 
 with chorea alone, and the group of unexplained 
 cases. Are these the result of rheumatic endocar- 
 ditis ? Taking the latter first, their number is not 
 large. Dr. Goodhart, out of 248 cases of heart-disease, 
 found all but 55 associated with either rheumatism 
 or chorea. 4 If from this remainder we take the con- 
 
 1 Diseases of Infancy and Childhood, 7th ed., p. 553. 
 
 2 Diseases of Cldldren, pp. 528-9. 
 
 3 Lancet, October 31, 1885, p. 795. 
 
 4 Diseases of Children, p. 529. 
 
RELATION OF ENDOCARDITIS TO CHOREA 95 
 
 genital, pysemic, and fever cases there are few left 
 unexplained, and of these few many are probably 
 rheumatic, where slight arthritis has been overlooked 
 or been absent. There remain, then, practically only 
 the choreic cases — i.e. the cases where organic heart- 
 disease arises in chorea, but is not known to be 
 associated with any manifestation of articular rheu- 
 matism. Are these to be included as examples of 
 rheumatic endocarditis ? In my judgment most of 
 them — possibly all. The antecedent probability is 
 largely in favour of their rheumatic origin. My 
 reasons are these. The cardiac affection of chorea 
 is, as a rule, organic, not merely functional. Func- 
 tional murmurs do no doubt arise occasionally in 
 chorea— e.g. the ordinary hsemic murmur of the 
 pulmonary orifice. But that the mitral murmur of 
 chorea is not usually of functional origin seems to 
 be established by the following considerations : — 
 
 1. If the mitral murmur were what is called 
 hseinic, it is strange that in this particular disease — 
 chorea alone — the mitral valve should be the seat of 
 it, such functional disturbance being in other con- 
 ditions associated with the pulmonary and aortic 
 orifices ; and further, if a mitral hsemic murmur did 
 exist, a fortiori a pulmonary one should exist also, 
 but it does not. Moreover, the mitral murmur of 
 
96 THE MITRAL MURMUR OF CHOREA 
 
 chorea comes early as a rule, before anamiia and 
 debility arise. 
 
 2. The hypothesis that the mitral murmur of 
 chorea is commonly spasmodic or paretic as suggested 
 by Dr. Sturges, although plausible and ingenious, is 
 a pure hypothesis, unsupported by positive evidence. 
 It is rendered improbable by the fact that, as a 
 matter of clinical observation, the murmur does not 
 arise especially in connection with irregular action 
 of the heart, as I have repeatedly satisfied myself; 
 and, moreover, as Dr. Osier l points out, the general 
 immunity of involuntary muscle in all choreic dis- 
 turbance is against the theory of spasm ; while, as 
 to paresis, the murmurs have no special association 
 with paretic chorea. 
 
 3. In fatal cases of chorea endocarditis is almost 
 invariably found post mortem. There is no other 
 disease in which it is so constant. 2 
 
 4. In fatal cases of valvular disease arising in 
 association with chorea, the changes found in the 
 valves post mortem are identical with those from 
 endocarditis from other causes, while the valve 
 chiefly affected is the mitral valve, the one most 
 liable to endocarditis. 
 
 1 American Journal of Medical Sciences, vol. xciv. new series, 
 p. 374. 
 
 - Ibid. p. 375. 
 
RESULTS OF CLINICAL OBSERVATION 97 
 
 These considerations are borne out by careful 
 clinical observations, such as those of Dr. Stephen 
 Mackenzie and Dr. Osier. The former found the 
 murmur of chorea persistent in 60 to 80 per cent. 
 from one to five years afterwards. 1 Dr. Osier, in- 
 dependently pursuing* a similar inquiry, comes to a 
 like result. In 110 cases of chorea examined two 
 years afterwards, organic heart-disease was found in 
 54. 2 A large proportion of choreic murmurs there- 
 fore persist or reappear, and in some instances do 
 not develop until after the chorea, when all motor 
 and paretic disturbance has long ceased. 
 
 The valvular affection of the heart, then, in 
 chorea is, in the vast majority of cases, organic, 
 due to endocarditis. Is the endocarditis rheumatic ? 
 The evidence in favour of this is extremely strong-. 
 First, there is the frequent association of articular 
 rheumatism with chorea and endocarditis together ; 
 secondly, the frequent association of articular rheu- 
 matism with the two independently, with chorea on 
 the one hand, and with endocarditis on the other ; 
 thirdly, the especial association of endocarditis with 
 those cases of chorea which are also associated with 
 articular rheumatism. The great proportion of cases 
 
 1 Trans. Int. Med. Cong. 1881, vol. iv. pp. 100, 104. 
 
 - American Journal of Medical Sciences, vol. xciv. new series. 
 
93 CONNECTION WITH RHEUMATIC CHOREA 
 
 of endocarditis which arise in connection with chorea 
 arise in choreas connected with articular rheu- 
 matism. Endocarditis picks out, so to speak, the 
 rheumatic cases. In 84 cases of chorea of which 
 I took precise notes there was a history of articular 
 rheumatism in either the patient or near blood- 
 relatives in 62. In the remaining 22 there was no 
 such history. Of the 62 cases of chorea with rheu- 
 matic history, 43, or 69 per cent., had organic heart- 
 disease. In the 22 choreas without rheumatic his- 
 tory there were only 6 cases of organic heart-disease, 
 or 27 per cent. 1 The statistics of the Collective 
 Investigation Committee tell the same story. They 
 yield 50 per cent, of heart affection in choreas with 
 rheumatic history, as against 35 per cent, in those 
 without rheumatic history: and these statistics, as 
 stated, necessarily give too low an estimate of the 
 rheumatic influence, since the only test of rheu- 
 matism admitted is the antecedent or concurrent 
 association of articular affection. Yet the evidence 
 afforded by nodules, by pericarditis, and by erythema 
 exudativum is of considerable weight. How sugges- 
 tive, for example, are cases of chorea such as that 
 of the child I exhibited at the last lecture, who has 
 a plentiful crop of nodules accompanying endocar- 
 1 Lancet, October 31, 1885, p. 7"J4. 
 
THE HARMONY OF INCIDENCE ON THE SEXES 99 
 
 ditis, yet in whom there is no history of articular 
 affection at any time, either in the patient or her 
 family ; l and that of the girl now under my care 
 at St. Mary's Hospital, 2 who came in with chorea, 
 and has since developed pericarditis, with only 
 the slightest and most transient articular affection, 
 lasting no longer than twenty-four hours. Lastly, 
 there is the indirect evidence afforded by the signi- 
 ficant fact to which I drew attention in the last 
 lecture — namely, the singular harmony which exists 
 between the incidence of articular rheumatism, of 
 chorea, of rheumatic chorea, and of choreic heart- 
 disease, upon the sexes between the ages of eleven 
 and fifteen. If the statistics are to be trusted, girls 
 are from two to three times as liable as boys to arti- 
 cular rheumatism, to chorea, to rheumatic chorea, 
 to heart-disease in rheumatic chorea, and to heart- 
 disease in chorea where there is no history of rheu- 
 matism. And apart from all direct evidence of rheu- 
 
 1 Sarah M , admitted to the Hospital for Sick Children, 
 
 November 15, 1888, under Dr. Barlow. Since the above was written 
 a very significant series of events has occurred — namely, acute 
 tonsillitis, followed after an interval of a fortnight by pain, swell- 
 ing, and tenderness of one small joint only, that of the right middle 
 finger; this lasted two days, and then disappeared. On the same 
 day pericardial friction was discovered, and still continued when this 
 note was taken a week later. 
 
 2 Kate B , Albert Victor ward, January 1S89. 
 
100 THE THEORY OF STRAIN OR SHOCK 
 
 matism, when endocarditis appears in association 
 with, chorea, in view of the fact that rheumatism is 
 the chief cause of endocarditis on the one hand, and 
 that it is the only disease closely associated with 
 chorea on the other, is it not more reasonable to 
 suppose, when endocarditis and chorea occur together, 
 that rheumatism is at the root of both, rather than 
 that the valvular inflammation is set up by disordered 
 muscular action, or that it depends upon some mys- 
 terious condition connected with chorea of which we 
 know nothing? 
 
 It has been suggested that strain, or shock, or 
 violent action of the valves is the source of choreic 
 endocarditis. This is, I think, untenable, for many 
 good reasons. In the first place, the heart does 
 not act violently in chorea, but feebly ; tension is 
 lessened, not increased. Secondly, in diseases such as 
 exophthalmic goitre, where the valves flap to with 
 great force, valvulitis is not thereby set up, although 
 a functional murmur is sometimes developed. 
 Thirdly, heart-disease does not arise especially in 
 connection with chorea associated with fright, when 
 a sudden strain might be postulated, but in connec- 
 tion with chorea associated with rheumatism equally 
 whether fright is or is not present as a co-factor. 
 The most cogent argument of all, however, is that 
 
ARGUMENT FROM PERICARDITIS 101 
 
 drawn from pericarditis. Pericarditis arises in 
 chorea quite apart from any articular affection as 
 often in proportion to its general frequency as endo- 
 carditis. How is this to be accounted for ? Neither 
 the strain hypothesis, the paretic hypothesis, nor 
 the spasm hypothesis will explain choreic pericarditis 
 any more than it will explain choreic nodules or 
 choreic erythema. So far the only reasonable ex- 
 planation of the endocarditis of chorea, as of the 
 pericarditis, is that it is of rheumatic origin. As 
 Dr. Barlow has surmised, and as I shall endeavour 
 to demonstrate presently, the active morbid change 
 in the cardiac valves in subacute endocarditis 
 appears to be analogous to that in the subcutaneous 
 fibrous tissues giving rise to nodules. Such nodules 
 are frequently developed without concurrent arti- 
 cular rheumatism, but with endocarditis, in the 
 course of chorea. Is it not probable that in choreic 
 endocarditis a subacute change of this kind goes on, 
 and that many of the murmurs at least which come 
 and go or develop afterwards are really due to this 
 cause, rather than to functional disorder? The 
 endocardial change may be sometimes just as pass- 
 ing or recurrent as we have seen the nodular de- 
 velopment to be in many cases. 
 
 Turning now from the evidence that the endo- 
 
102 SUBACUTE PROGRESSIVE ENDOCARDITIS 
 
 carditis of childhood is chiefly rheumatic to the con- 
 sideration of the condition in itself, I have said that 
 it is less acute, severe, and passing than with adults ; 
 that it is especially liable to relapse, and recur, or 
 smoulder on for weeks or months. This is well 
 
 shown in the case of W. S (Series VIII.) , where 
 
 endocarditis, beginning in 1886, occurred again in 
 1887, and then continued with arthritis, chorea, 
 erythema, and nodules, pretty constantly, until the 
 rheumatic series closed in death in March, 1888. 
 
 The cases of H. W. B (Series I.), C. H. B 
 
 (Series II.), and J. T (Series X.) afford addi- 
 tional illustrations. 
 
 In the case of B. H , a boy aged six years and 
 
 a-half, now under my care in Great Ormond Street 
 Hospital, a similar slow recurrent endocarditis is 
 going on. The boy has never had any sign of what 
 is ordinarily termed rheumatism, except some pains 
 in the feet attributed to an accident, with pain in 
 the cardiac region and sweating; but there is a 
 history of rheumatism on the mother's side. He 
 has a well-marked mitral regurgitant murmur and 
 reduplicated second sound at the apex. Nodules are 
 being developed ; he grows more pale and ill ; has 
 had two attacks of sudden dyspnoea, with signs of 
 circumscribed pneumonia, evidently embolic. Fresh 
 
SUBACUTE PROGRESSIVE ENDOCARDITIS 1C3 
 
 nodules continue to appear ; the murmur grows 
 harsher and more musical. There can be little doubt 
 that chronic endocarditis is going on, and that the 
 injury to the heart-structures is progressive. 
 
 A more striking instance still is that of H. 
 G , a boy aged fourteen, whose case I have pub- 
 lished before, 1 and which I shall therefore allude 
 to only very briefly here. The patient had large 
 nodules on the flexor tendons of the palms and 
 fingers, accompanied by subacute recurrent endo- 
 carditis, which had probably commenced with an 
 attack of slight arthritis about a year previously. 
 The joint rheumatism had received no serious atten- 
 tion; the heart was not examined. The boy con- 
 tinued to follow athletic sports, with the result of 
 setting up extreme regurgitant aortic disease and 
 dilatation of the left ventricle. It is interesting to 
 note, in passing, that the boy's sister had had chorea 
 without any articular rheumatism ; his grandmother, 
 rheumatic fever. 
 
 The eruption of subcutaneous nodules is associated 
 with grave progressive endocarditis as closely as with 
 progressive pericarditis ; and I think an examination 
 of the pathological process going on in the valves in 
 
 1 Lectures on Heart-Disease in Children {Lancet, October 17, 
 1885, p. 703). 
 
104 RHEUMATIC INFLAMMATION OF MITRAL VALVE 
 
 Fig. 1. 
 
 
 
 I. • 
 r 
 
 Microscopic appearances in a section of the mitral valve in a case 
 of rheumatic endocarditis in a child, showing proliferation and 
 
 cell-infiltration of subendothelial fibrous tissue. (Ellen M , 
 
 aged eight years and a-half ; Hospital for Sick Children, Great 
 Onnond Street ; Dr. Barlow ; March 28, 1883. Arthritis., nodules, 
 morbus cordis, purpura.) 
 
OF SUBCUTANEOUS NODULE 105 
 
 Fig. 2. 
 
 Microscopic appearances in a section of subcutaneous tendinous 
 nodule in acute rheumatism, showing active proliferation and 
 
 cell-infiltration of fibrous tissue. (John T , aged seven years 
 
 and a-half : Hospital for Sick Children, Great Ormond Street ; 
 died August 6, 18S8. Chorea, arthritis, endocarditis, pleurisy, 
 nodules, pericarditis.) 
 
100 MORBID CHANGES IN VALVES AND NODULES 
 
 endocarditis of this kind explains the connection. 
 The inflammatory process in the valves, as Dr. Barlow 
 ventured to anticipate seven years ago, appears to be 
 identical with that met with in the nodules — viz. 
 nuclear proliferation, cell infiltration, spindle cells in 
 process of transformation into fibrous tissue, wavy 
 bands of fibres, and vessels. The microscopic ap- 
 pearances of a thin section of the mitral valve of the 
 patient, Ellen M , are shown in the speci- 
 mens exhibited, for which I am indebted to Mr. 
 Priestley, and reproduced in the drawing (Fig. 1), and 
 those in a subcutaneous nodule in Fig. 2. The pro- 
 liferation and cell infiltration of the fibrous tissue 
 which forms the framework of the valve is the most 
 conspicuous feature, and it is to the proliferation of 
 this layer that most of the swelling is due. There 
 is, moreover, infiltration of the whole thickness of the 
 valve with round cells, nuclei, or leucocytes. In 
 some specimens there can be seen distinct proliferation 
 of the endothelium, and in some a deposit of fibrin 
 on the surface in which leucocytes are visible. But 
 the chief change — the greatest and most important 
 change, that which causes the thickening and rigi- 
 dity — is the proliferation of fibrous tissue, which is 
 the leading feature of the morbid process seen in 
 the subcutaneous nodule. Now, looking at the 
 
IRRITATION OF FIBROUS TISSUES 107 
 
 affection of the fibrous tissues of the joints of the 
 subcutaneous fascia, of tendons, of the pericar- 
 dium, and of the endocardium, it appears that the 
 materies morbi of rheumatism, whatever its nature, 
 sets up similar irritant changes in fibrous tissues in 
 all these parts. But since the nodules are rarely 
 found in adults, although so common in children, and 
 that endocarditis and pericarditis are likewise more 
 common in children, while arthritis, on the other 
 hand, is less severe, it would appear further, that in 
 early life the fibrous tissues of subcutaneous fasciae, 
 of tendons, of pericardium, and of endocardium are 
 far more sensitive to the morbid stimulus, more easily 
 excited to proliferation, than the same tissues in later 
 life; while, on the contrary, the joint fibrous tissues 
 are less susceptible to the poison in children than 
 in adults. It seems clear, moreover, that the 
 susceptibility of subcutaneous fibrous tissues and 
 the susceptibility of the fibrous tissues of endo- 
 cardium and pericardium go together ; and this cir- 
 cumstance, as suggested before, affords a possible 
 clue to the nature of the evanescent mitral murmurs 
 of rheumatic arthritis and chorea. The rapid de- 
 velopment of the nodules in some instances in the 
 course of a few days even, and their equally quick 
 disappearance on occasion, suggest that the murmur 
 
108 TRANSIENT ORGANIC MURMURS 
 
 which arises and disappears, and which is styled 
 functional, is really caused by the development of 
 similar inflammatory cell-growth, in the valves and 
 chordse, which may subside in them as quickly as 
 we see it does in a subcutaneous nodule. This 
 correlation of nodules and valvulitis gives the ap- 
 pearance of the former great clinical significance, 
 as probably indicative of a similar change going 
 on in endocardium or pericardium, or both. When 
 the nodules are few or small, they must be regarded 
 as serious signs ; when large and numerous, they are 
 grave warnings of the existence of a condition of 
 ultimate danger. 
 
 . Ulcerative endocarditis is most rare in the 
 rheumatism of children, since it is met with chiefly 
 in patients broken down by drink and disease. The 
 earliest age at which I find its occurrence recorded 
 is in a patient of my own at the Children's Hospital, 
 
 Annie I , a girl of eight. 1 Senator observed it 
 
 in a boy of fourteen, and Dr. Ord in a girl of sixteen. 
 It possesses no special features which require notice 
 here. 
 
 Rheumatic endocarditis in children, as in adults, 
 attacks mitral, aortic, and tricuspid valves, the former 
 by far the most commonly; mitral regurgitation 
 
 1 Post-mortem Book, vol. iv. 1887. 
 
MITRAL STENOSIS 109 
 
 is the most usual resulting lesion, although mitral 
 stenosis is far more frequent than is generally sup- 
 posed. It is in the latter that the chief interest 
 centres. 
 
 It is well "known that mitral stenosis is met with 
 most frequently in young women. Of 263 cases 
 collected by Sir Dyce Duckworth, 1 there were 177 
 females and 86 males. And this relation between 
 the sexes probably holds good in the case of children, 
 in accordance with the great preponderance of heart 
 disease in girls between eleven and fifteen. Mitral 
 stenosis is in its origin especially a lesion of child- 
 hood and early life. I find 33 cases with presystolic 
 murmur and 24 with reduplicated second sound at 
 the apex, indicating commencing stenosis, out of 
 273 cases of organic heart-disease in children of 
 which I have accurate record. The youngest 
 patients were two boys of four. Yet the age of the 
 youngest patient in Sir Dyce Duckworth's list was 
 fourteen. Dr. Fagge had no instance under ten; 2 
 Dr. Hayden two only of seven years old. 3 
 
 It was formerly taught that mitral stenosis is less 
 often rheumatic than any other valvular affection. 
 As a matter of actual fact, this form of heart-disease 
 
 1 Etiology of Mitral Stenosis (pamphlet). 
 
 2 Guy's Hospital Rej)orts, Series 3, vol. xii. 
 
 3 Diseases of the Heart, (Dublin, 1875), p. 964 et seq. 
 
110 USUALLY OF RHEUMATIC ORIGIN 
 
 — in children at any rate — is especially rheumatic, 
 and because it is so associated with the rheumatic 
 endocarditis of childhood I lay stress upon it here. 
 Dr. Sansom found SO per cent, with a history of 
 articular rheumatism or of pains. 1 Sir Dyce 
 Duckworth's cases yield 60 per cent. My own 
 statistics are still more remarkable. Taking children 
 alone, I find this striking evidence of its rheumatic 
 relation. Of 57 cases, in 44 there was acute rheuma- 
 tism in the patient ; in 20 of these 44 in the family 
 also ; in 4 more in the family alone, leaving 9 only in 
 which there was no rheumatic history. Putting out of 
 the question family history, then, there was personal 
 history of rheumatism in 44 out of 57, or 79 per cent. 
 It is in the period of childhood that mitral 
 stenosis most commonly commences. The reason 
 why it has not been more frequently observed is 
 perhaps due to the fact that it is at this period 
 usually in the initial stage. It is, as Dr. Sansom 
 has shown, 2 the special product of the slight, sub- 
 acute, slow, recurrent, rheumatic endocarditis which 
 is characteristic of childhood. The stenosis does not 
 generally reach the degree when it is proclaimed by 
 the loud, vibrating, prolonged presystolic murmur, 
 
 1 Lettsomian Lectures, 2nd ed. p. 130. 
 - Ibid. 1886, p. 80. 
 
ARISES MOST COMMONLY IN CHILDHOOD 111 
 
 until a few years have passed. The slight rumble, 
 or the reduplicated second sound, escapes notice, or 
 attention is drawn away from it by an accompanying 
 regurgitant bruit. Hence it is discovered later, with 
 startling frequency, just after childhood. Cases are 
 met with in which this condition is found to exist 
 without any rheumatic attack to explain it. In these 
 instances I believe it has had its first origin in 
 childhood, arising unnoticed with a slight arthritis, 
 or a crop of nodules, or a chorea, or alone, as the sole 
 manifestation of a rheumatic outburst. 
 
 The earliest sign of mitral stenosis is reduplication 
 of the second sound at the apex. Dr. Sansom has 
 observed generally, 1 that c reduplication of the first 
 or of the second sound is an early sign of stenosis.' 
 But I would limit the statement to reduplication at 
 the apex, audible over the mitral area only, or at 
 least having its maximum intensity there. Dr. 
 Sansom gives two cases 2 in which this local limitation 
 was observed, but he does not differentiate them 
 from the rest. Now, although reduplication of both 
 first and second sounds, audible over the aortic and 
 pulmonary valves at the base of the heart, occurs in 
 certain cases of mitral stenosis, it is not this with 
 
 1 Lettsomian Lectures, p. 22. 
 
 2 Trans. Jfed. Soc. vol. v, p. 204. 
 
112 THE EARLIEST SIGX OF MITRAL STENOSIS 
 
 which I am concerned; that is not an early sign 
 according to my experience. It is reduplication at 
 the apex which is the significant early sign ; basic 
 reduplication usually comes later, with a pronounced 
 presystolic murmur or with mitral regurgitation, and 
 it is explained readily enough by the difference in 
 tension in the pulmonary artery and aorta, causing 
 asynchronous closure of their respective valves. It 
 appears, however, to be generally assumed that this 
 asynchronism of the pulmonary and aortic valves will 
 account for all reduplication. But it certainly entirely 
 fails to explain reduplications audible only at the 
 apex. If the doubling of the sound were caused by 
 the asynchronous closure of the aortic and pulmonary 
 valves, it would be audible over their position — i.e. 
 at the base of the heart, — but it is not. Dr. Sansom 
 saw this difficulty and to him the credit of a more 
 correct explanation is due. He suggests that the 
 first of the two second sounds is the normal one 
 caused by the simultaneous closure of the pulmonary 
 and aortic valves, and the second by the sudden 
 tension of the mitral flaps as the ventricle relaxes. 
 The blood in the auricle, in a state of increased 
 tension, drives open the mitral door, and, rushing 
 round the sides of the ventricle, gets underneath the 
 curtains — the anterior one of which, as Dr. Macalistcr 
 
DOUBLE SECOND SOUND AT THE APEX 113 
 
 has shown, is stretched tight from the basal ring to the 
 top of the papillary muscle — and thus gives rise to a 
 sound of tension. 1 This explanation is, I think, cor- 
 rect in the main — so far as this, at least : that one of 
 the two second sounds — viz. the second — is mitral 
 in origin. It is not audible at the base ; only one 
 sound is audible over the aortic and pulmonary area, 
 while two are audible over the mitral area. The one 
 which is heard over the mitral only must be pro- 
 duced there. It seems to me that the most probable 
 explanation is that the first of the two second sounds 
 is the normal one caused by the click of the basic 
 valves, as Dr. Sansom suggests, the pulmonary ele- 
 ment being accentuated and rendered louder by in- 
 creased resistance in front. The second of the two 
 second sounds is due to the smack or click of the 
 forcible opening of the swollen, rigid mitral with 
 shortened chords, kept closed with difficulty by the 
 contracting ventricle, and springing back suddenly as 
 the ventricle relaxes and exerts its suction power, 
 aided by the increased tension in the left auricle, 
 rather than by the auricular contraction, which occurs 
 later. The suction power of the relaxing ventricle 
 has been shown by Marcy and Fick, and Goltz and 
 G-ubler, to be considerable at the beginning of dia- 
 1 LetUomian Lectures, 2nd ed. p. 123. 
 
 I 
 
114 THE EARLIEST SIGN OF MITRAL STENOSIS 
 
 stole, possibly as much as 23 millimetres of mercury, 
 independent of respiration. 1 This view is supported 
 by the fact that, after the second of the two second 
 sounds — i.e. the one which Dr. Sansom and myself 
 take to be the mitral sound — there is in some in- 
 stances a soft bruit, a distinct diastolic murmur, 
 probably due to the rush of blood through the 
 narrowed aperture caused by the auricular contrac- 
 tion which comes, not at the very beginning of 
 diastole, but a moment after its commencement. 
 Reduplication of the second sound at the apex, then, 
 is, I think, the earliest sign of swelling and rigidity 
 of the mitral fla/ps, and consequent imperfect opening 
 of the valve. Whether the explanation I have given 
 be accepted or not, there can be no question as to 
 the connection of this morbid sound with early mitral 
 stenosis, and of its clinical significance. 
 
 Hypertrophy and Dilatation. — These secondary 
 changes proceed more rapidly in children than in 
 adults. The first develops apace, in accordance with 
 the general law before mentioned — that the tissues 
 respond to stimulation and grow more rapidly in 
 childhood; and the second — dilatation — perhaps 
 because the tissues are more soft and yielding. 
 
 The following is an example of rapid dilatation 
 1 Macalister : Brit. Med. Jour. October 28, 1882, p. 123. 
 
HYPERTROPHY AND DILATATION 115 
 
 and hypertrophy. George B , aged six, was 
 
 admitted into Great Ormond Street Hospital on April 
 29, 1879, with general cardiac dropsy. He had had 
 scarlatina with articular rheumatism six months 
 before. After death the heart was found to be 
 hypertrophied and still more dilated, weighing seven 
 ounces — as large as that of a child of eleven or 
 twelve. There was no valvular lesion of any kind, 
 except dilatation of the orifice ; and no history of any 
 rheumatic affection previous to the scarlatina. 
 
 Look/^again, at the case of Harold G , with 
 
 aortic regurgitation, previously mentioned. The 
 first attack of rheumatism was only sixteen months 
 before I saw him, and he had already enormous 
 enlargement, chiefly dilatation, of the left ventricle. 
 Observation of these cases in hospital shows that 
 these changes advance at a rate unknown in later 
 life. 
 
 As hypertrophy develops rapidly in children, so 
 compensation is usually for a time exceptionally 
 complete, and, as a further result of this effective 
 compensation, great enlargement of the liver and 
 spleen, pulmonary apoplexy, and extreme dropsy are 
 rare in the younger children, becoming more com-' 
 mon as age advances. It is an unusual thing to see 
 a little child blue, turgid, and waterlogged — a sight 
 
116 ENGORGEMENT OF LIVER— DROPSY 
 
 so sadly frequent in the last stage of mitral disease 
 in adults. Dr. Goodhart has observed these facts, 
 and attributes them to reduction of the whole blood- 
 supply as part of the general wasting, which is so 
 conspicuous a feature. This probably plays some 
 part in addition to efficient compensation. But there 
 is still another reason. Children with severe heart- 
 disease, as a rule, die from other causes before the 
 stage of grave tricuspid leakage is reached. For in 
 children the mode of death from mitral disease 
 differs from that we see in later life. Instead of 
 engorged liver and lungs, with blueness, extreme 
 dyspnoea, and general dropsy, there is rapid wast- 
 ing, progressive ansemia, feebleness, and death from 
 asthenia rather than from the direct injury to the 
 mechanism of circulation, unless it be the strangling 
 grip of pericardial exudation and adhesion. 
 
 Scarlatinal Rheumatism. — The account of the 
 various phases of rheumatism would be incom- 
 plete without some. reference to the scarlatinal affec- 
 tion. An articular inflammation appears now and 
 again in the course of scarlet fever, which can in no 
 way be distinguished from that of acute rheumatism. 
 It is often accompanied by endocarditis or peri- 
 carditis, and sometimes by chorea. Henoch 1 records 
 1 Diseases of Children, p. 30 (Eng. Trans. Sampson Low, 1883). 
 
SCARLATINAL RHEUMATISM 117 
 
 a case in which acute arthritis appeared in the first 
 week, followed by mitral murmur and chorea. This 
 scarlatinal rheumatism, although it may come late, 
 in most cases arises early; Dr. Barlow noted it 
 as early as the third day. 1 In a series of cases 
 observed by Dr. Ashby of Manchester the symptoms 
 supervened with great regularity at the end of the 
 first week. The endocarditis or pericarditis which 
 comes late in the course of scarlatina are possibly 
 uremic; but uraemia does not set up inflammation 
 of joints. Dr. Ashby inclines to the view that the 
 arthritis is of septic origin, due to foul throat, or 
 otitis, or empyema, and not a true rheumatism. The 
 theory of septic poisoning, indeed, carries us a step 
 further than the ursemic, for septicaemia produces 
 arthritis as well as pericarditis and endocarditis ; 
 and septicaemia does undoubtedly arise in scarlatina 
 in the way mentioned, as I have seen more than once. 
 But then the articular affection of scarlatina is not 
 especially associated with bad throats, or otitis, or 
 empyema, or with other signs of septicaemia ; more- 
 over septicaemia will hardly explain early scarlatinal 
 rheumatism, or the occasional concurrence of chorea. 
 It seems clear that either genuine acute rheumatism 
 does occur in the course of scarlatina, or else that 
 
 1 Brit. Med. Jowr. September 15, 1881, p. 510. 
 
118 RHEUMATOID ARTHRITIS 
 
 the scarlatinal virus itself occasionally produces an 
 inflammation of joints and serous membranes, and 
 a nervous choreic disturbance analogous to and in- 
 distinguishable from that set up by the rheumatic 
 poison. It is curious to observe, too, as previously 
 mentioned, that the especial liability to acute ar- 
 ticular rheumatism, which is so marked in girls, 
 extends to this scarlatinal form, as shown by Dr. 
 Gresswell ; the numbers being twenty girls to nine 
 boys, the inequality between the sexes being most 
 marked after ten years of age. 
 
 Rheumatoid Arthritis. — I had it in mind when I 
 planned these lectures to say something of rheu- 
 matoid arthritis. But the shortness of time and the 
 length of the subject prevent my finding place for it. 
 I will merely say that, although it is uncommon in 
 childhood, it does occur, and, as Sir A. Garrod long 
 ago pointed out, sometimes in its most severe and 
 intractable form. The disease in children appears 
 to be due to the same causes as 'in later life, and 
 to differ in no material respect from the type with 
 which we are familiar in adults. 
 
 Treatment. — Almost the whole interest and im- 
 portance of rheumatism in children centres in the 
 cardiac inflammation and its results. The one great 
 
TREATMENT OF GENUINE RHEUMATISM 119 
 
 aim and object of treatment should be to minimise 
 this danger as much as possible ; and the first point 
 which I would urge is the necessity of being con- 
 stantly on guard against an insidious attack of endo- 
 carditis or pericarditis. I have shown how it may 
 accompany the slightest articular affection — may 
 even arise without accompanying arthritis of any 
 kind; associated with chorea, or an exudative ery- 
 thema, or an eruption of subcutaneous nodules; or 
 it may arise apart from any known rheumatic phase 
 with an indeterminate febrile attack of apparent 
 insignificance. It is essential, then, to examine the 
 heart carefully in every case of the slightest- articular 
 affection — even a stiff neck or a stiff knee ; and in 
 chorea, in tonsillitis, in erythema, in an evolution of 
 nodules, and, indeed, in every pyrexial condition of 
 every form. Whenever there is suspicion of rheu- 
 matic inflammation — even if no cardiac affection be 
 perceptible — enforce absolute rest in bed. Complete 
 physical repose and external warmth are of the 
 first, possibly of vital, importance. Cases of slight 
 rheumatism are, as a rule, treated far too lightly hy 
 both parents and doctors. What a vast difference it 
 would have made in the future condition of the 
 schoolboy, H. G , for instance, if, instead of being 
 
120 DRUGS IN RHEUMATISM 
 
 allowed to follow athletic sports, and thus strain his 
 heart's muscle and court fresh chill, he had been kept 
 secure in rest and warmth. Dr. Sibson found that 
 a much larger proportion of cases — more than two 
 to one — treated by absolute rest escaped permanent 
 heart-mischief than those allowed free action. 
 
 With regard to drugs, I may point out that the 
 heroic treatment by large and repeated doses of 
 salicylate of soda is rarely called for in the rheu- 
 matism of children, since the articular affection is 
 usually slight, and the' pyrexia as a rule not severe ; 
 for the salicylates appear to exert no favourable 
 influence upon any rheumatic phase, except only 
 arthritis and tonsillitis. Salicin may be given in 
 place of salicylate of soda in most articular cases 
 with advantage, as being less depressant — and with 
 the salicin, alkalies. The general evidence of the 
 statistics of the Collective Investigation Committee 
 supports the conclusions of Dr. Fuller and Dr. 
 Dickinson, that cardiac inflammation is less frequent 
 and pronounced under their influence than under 
 any other form of treatment. It would be interesting 
 to note how full treatment by alkalies affects the 
 development and duration of subcutaneous nodules, 
 a point not yet ascertained. 
 
CONCLUSION 121 
 
 It remains only, Mr. President and gentlemen, 
 for me to thank you cordially for the great honour 
 you have done me in inviting me to deliver this 
 course of lectures, and to thank my audience for 
 their kind and indulgent attention to what I have 
 laid before them, 
 
INDEX. 
 
 AS£. C'HO 
 
 A5"-EMIA, in children, rernarh- disease :n the senes frcm 
 
 si- erheo: : rhennaarisna in eleven to fifteen, 58, 99 j 
 
 pro i ; o-ins-. 41 rheumatoid arthritis, 118 
 
 rcuenrlv =e: up 
 6; dis- 
 
 :s :::t: :: sna- 
 the rhennaatie 
 : : -lav— r. v. 
 
 its 
 
 of eh:rea vv:h. -1--'"': leit;:;.::;-;:-. 
 
 searle: r-ver stevlallT :-.--;- ri:n :f 1t:^:".\- 
 ciarea i 51. ■:_ harmony to chorea and 
 
 of incidence of arthritis, - 67 ; its associati 
 
 chorea, ana choreic hear: eardiris. r-2 : aa: 
 
124 
 
 INDEX 
 
 DIL 
 
 carditis, 9~-100; the organic 
 orio-in of the mitral murmur 
 in, 96, 97 
 
 Dilatation, development of, 
 
 114 
 Dropsy; extreme rarity of, in 
 
 young children, 115 
 Drugs, use of, in the treatment 
 
 of rheumatism in children, 
 
 120 
 
 Endocarditis, commonly 
 arises from rheumatism, 6 ; 
 more frequent in children 
 than in adults, 8 ; its order 
 in the combinations of the 
 rheumatic series, 10-22 ; 
 characters of, in childhood, 
 92, 102 ; relation of, to rheu- 
 matism, 93, 100, 107; statis- 
 tical evidence of the connec- 
 tion, 94, 98 ; its relation to 
 chorea, 95-100; almost in- 
 variably found post-mortem 
 in fatal cases of chorea, 96 ; 
 the theory of strain or shock 
 as the source of choreic en- 
 docarditis, 100 ; its relation 
 to the evolution of nodules, 
 101-108 ; examples of the 
 subacute progressive form, 
 102 ; similarity in morbid 
 changes in valves and no- 
 dules, 103-108 ; microscopic 
 appearance of mitral valve 
 in a case of rheumatic endo- 
 carditis, 104, 106; rarity of 
 the ulcerative form in chil- 
 dren, 108 
 
 Erythema exudativum. fre- 
 quency results from rheu- 
 matism, 6 ; its occurrence 
 in the rheumatic series, 15, 
 19-21 ; statistical evidence 
 
 HYP 
 
 of its connection with rheu- 
 matism, 46 ; various forms 
 of, 47 ; appears mostly in 
 the marginate and urti cari- 
 ous forms, 47 ; association of 
 erythema nodosum with 
 arthritis, 48 ; liability of 
 young girls to erythema 
 nodosum, 49 
 
 Family predisposition, in- 
 fluence of, in rheumatism, 
 26-30 ; the evidence of 
 statistics, 27 ; cases illus- 
 trative of, 28 ; children of 
 rheumatic parents frequently 
 angemic, 41 ; its influence in 
 chorea, 53, 61-63 ; rheumatic 
 family history in ' growing 
 pains,' 64 
 
 Girls, young, especially sus- 
 ceptible to arthritis, 24-26 ; 
 to scarlatinal rheumatism, 
 25 ; to erythema nodosum, 
 49 ; to chorea and organic 
 heart disease, 58, 59 
 
 ' Growing pains,' rheumatic 
 family history in, 64 
 
 Heart disease, in rheumatism, 
 percentage of children and 
 adults affected, 8 ; harmony 
 of incidence on the sexes 
 from eleven to fifteen of 
 heart disease, chorea, and 
 arthritis, 58, 99 ; signifi- 
 cance of subcutaneous no- 
 dules in, 74-76. See Endo- 
 carditis, Pericarditis, and 
 Mitral Stenosis 
 
 Hyperpyrexia, rheumatic, ra- 
 rity of, in children, 33, 34 
 
INDEX 
 
 32.- 
 
 HYP 
 
 Hypertrophy and dilatation, 
 rapid development of, in 
 children, 114; examples of, 
 115 ; the mode of death in 
 children differs from that in 
 adults, 116 
 
 PUR 
 
 nodules and in valves in 
 endocarditis, 103-108 ; mi- 
 croscopic appearance of a 
 nod ale in acute rheumatism, 
 105, 106 
 
 Mitral stenosis, proportion of 
 the sexes affected, 109 ; 
 arises most commonly in 
 childhood, 109-1 11 ; evidence 
 of its rheumatic relation, 
 110 ; earliest sign of, 111- 
 114 
 
 Nervous excitability, its rela- 
 tion to rheumatism, 67 
 
 Nervous shock, as a factor in 
 chorea, 55-57 
 
 Nodules, subcutaneous tendin- 
 ous; 5 ; rheumatism the sole 
 source of, 6, 7 ; at their 
 maximum in early life, 8 ; 
 their order in the rheumatic 
 series, 10-22 ; importance of, 
 as clinical signs of rheu- 
 matism, 69 ; common occur- 
 rence of, in children, 69 ; 
 their character, distribution, 
 and duration, 69-72 ; struc- 
 ture of, 72 ; their relation to 
 rheumatism, 73; specially 
 associated with the graver 
 forms, 74 ; serious in pro- 
 portion to their size and 
 number, 74, 75 ; clinical sig- 
 nificance of, 75, 108 ; their 
 connection with grave forms 
 of heart disease, 75, 76 ; 
 examples of their association 
 with pericarditis, 86-88 ; 
 their pathological relation 
 to fibrosis, 89 ; relation of, to 
 endocarditis, 1 01-108 ; simi- 
 larity of morbid changes in 
 
 Pericarditis, 5 ; rheumatism 
 the most common cause of, 
 6, 79 ; more frequent in 
 children than in adults, 8 ; 
 its varying position in the 
 rheumatic series, 12-22, 79 ; 
 the acute form rare in child- 
 hood, 80 ; examples of the 
 acute form, 81-83; associa- 
 tion of, with chorea, 82 ; 
 characteristics of the disease 
 in childhood, 83, 88 ; post- 
 mortem appearances, 84, 90 ; 
 cases of the subacute form, 
 85-88 ; its association with 
 nodules, 86-88, 101 ; signifi- 
 cance of nodules in, 88 ; 
 relation of nodules to fibro- 
 sis of the pericardium, 89 ; 
 effect of thickened pericar- 
 dium, 90 ; changes caused in 
 the fibrous tissues of the 
 pericardium by rheumatism, 
 107 
 
 Pleurisy, frequently an accom- 
 paniment of rheumatism, 5, 
 6 ; its position in the rheu- 
 matic series, 12-22 ; asso- 
 ciated with rheumatism in 
 two distinct ways, 76 ; two 
 examples of primary rheu- 
 matic pleurisy, 77, 78 
 
 Polyarthritis, 3 ; synovialis, 
 and rheumatica acuta, 3 
 
 Pulmonary apoplexy, rarity of, 
 in young children, ] 1 5 
 
 Purpura rheumatica, 50; its 
 probable connection with 
 rheumatism, 50 
 
126 
 
 INDEX 
 
 RHE 
 
 Rheum arthri ns, 3 
 
 Rheumatic, definition of the 
 term, 2, 7 
 
 Rheumatic fever, the extreme 
 expression of rheumatism 
 in adults, 2 
 
 Rheumatic series of diseases, 
 6; arthritis, 6, 23-10; chorea, 
 
 • 6, 51-68 ; endocarditis, 6, 
 91-106; erythema, 6, 46- 
 50; pericarditis, 6, 79-91; 
 pleurisy, 6, 76-78 ; subcu- 
 taneous tendinous nodules, 
 6, 68-76 ; tonsillitis, 6, 12- 
 16 ; varying order of the 
 series, 10-12; clinical ex- 
 amples of combinations of, 
 12-22 
 
 Rheumatic sore throat, 13 
 
 Rheumatism, definition of the 
 term, 2,7; acute articular, 
 symptoms of, 2 ; arthritis 
 only one manifestation of 
 the rheumatic state, 3 ; 
 other morbid conditions 
 prominent and constant in 
 children, 4 ; of childhood 
 most complete and repre- 
 senta'ive, 1; developments 
 of, 5 ; the rheumatic series, 
 6-22 ; broad conception of 
 the disease, 7 ; in children, 
 contrasted with that of 
 adults, 7-10; varying order 
 of succession of the rheu- 
 matic series, 10; combina- 
 tions of the series, 12-22 ; 
 the influence of sex, 23 ; 
 statistics of the sexes at 
 varying ages, 23 ; the influ- 
 ence of family predisposi- 
 tion, 26 ; statistics and ex- 
 amples of family predispo- 
 sition, 27-30; the arthritis 
 of childhood, 30-40; rarity 
 of hyperpyrexia in children, 
 34; examples of mistaken 
 
 SCA 
 
 diagnosis of arthritis in 
 children, 35-10 ; the ansemia 
 of, 11 ; connection of ton-" 
 sillitis with, 13 ; character- 
 istics of rheumatic tonsillitis, 
 43, 45 ; relation of erythema 
 to, 46-50 ; purpura rheuma- 
 tica, probably a minor ex- 
 pression of, 50; the connec- 
 tion of chorea with, 51-56 ; 
 scarlet fever specially asso- 
 ciated with arthritis., 51, 52, 
 116; relation of nervous 
 excitability to, 67 ; fre- 
 quency and importance of 
 subcutaneous tendinous 
 
 nodules in, 69 ; nodules 
 specially connected with the 
 graver forms of, 74 ; pleurisy 
 occurs in connection with, 
 in two distinct ways, 76 ; 
 is the most common cause 
 of pericarditis, 79, 107 ; 
 association of pericarditis 
 with other rheumatic phases, 
 79-88; relation of endocar- 
 ditis to, 93, 97-100, 107; 
 changes produced by, in the 
 fibrous tissues, 107 ; the 
 rheumatic origin of mitral 
 stenosis, 110; scarlatinal 
 rheumatism, 116 ; treatment 
 of rheumatic children, 118 ; 
 necessity of absolute rest 
 and warmth, 119 ; the use 
 of drugs in, 120 
 Rheumatoid arthritis, 118 
 
 Scarlatinal rheumatism, 
 susceptibility of young girls 
 to, 25, 118; statistics as to 
 the influence of sex in, 25 ; 
 its connection with the 
 phases of the rheumatic 
 series, 116, 117 
 
 Scarlet fever, especially asso- 
 
INDEX 
 
 127 
 
 SEX 
 
 ciated with acute rheuma- 
 tism, 51, 52, 116 
 
 Sex:, the influence of, in arti- 
 cular rheumatism, 23 ; pro 
 clivity of young girls to 
 various phases of the rheu- 
 matic series, 24, 25, 49, 58, 
 109; harmony of incidence 
 of arthritis, chorea, and 
 organic heart disease oh the 
 sexes from eleven to fifteen, 
 58, 99 
 
 Sore throat, rheumatic, 43 
 
 URT 
 
 Tonsillitis, 5; frequently 
 results from rheumatism, 6 ; 
 its occurrence in the rheu- 
 matic series, 10-20, 43 ; its 
 special connection with 
 arthritis, 43, 44 ; character- 
 istics of rheumatic tonsil- 
 litis, 44, 45 
 
 Urticaria, associated with 
 rheumatic disturbance, 47 
 
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