54 Lib. cit., pp. 77-278.
55 Lib. cit., p. 209. See also Dickinson in Lancet, i., 1869, 254; Bauer in Ziemssen's Cyclopæd., vi. 557.
Of the several forms of rheumatic cardiac inflammation, endocarditis is the most frequent, and in a large proportion of cases it may exist alone; pericarditis is also very often observed, but it seldom is found per se, being in the vast majority of cases combined with endo- and occasionally with myocarditis. It is generally the ordinary verrucose endocarditis that obtains. The ulcerative form occurs sometimes, and should be suspected if in a mild or protracted case of acute rheumatism endocarditis sets in with, or is accompanied by, rigors, and the general symptoms are of pyæmic or typhoid character or both, even although an endocardial murmur is not present, for extensive vegetating ulcerative endocarditis frequently exists without audible murmur. It is remarkable, as Osler has shown,56 how few instances of ulcerative endocarditis developing during the course of acute rheumatism are reported; and I would add that by no means all of these were examples of first attacks, chronic valvular lesions, the consequence of former illness, existing in many of them at the time of the final acute attack. Southey's57 patient, and both of Bristowe's,58 had had previous rheumatic seizures. However, Peabody's case,59 one of Ross's three cases,60 and Pollock's61 case appear to have been examples of ulcerative endocarditis occurring during a first attack of acute articular rheumatism. The united and thickened condition of two segments of the aortic valve in one of Ross's cases indicates old-standing disease, although no history of former rheumatism is given. Goodhardt62 has lately insisted upon the tendency of ulcerative endocarditis to appear in groups or epidemics, but the evidence is not conclusive.
56 Archives Médecine, vol. v., 1881; Trans. International Med. Cong., vol. i. 341.
57 Clin. Soc. Trans., xiii. 227.
58 Brit. Med. Jour., i., 1880, 798.
59 Medical Record N.Y., 24th Sept., 1881, 361.
60 Canada Med. and Surg. Journ., vol. xi., 1882, 1, and ib., vol. ix., 1881, 673.
61 Lancet, ii., 1882, 976.
62 Trans. Path. Soc. London, xxxiii. 52.