pericarditis--from the third to the sixth day in 10, and before the eleventh day in 30, or nearly one-half of the whole. That observer concludes "that in a certain small proportion of the cases, amounting to one-eighth of the whole," the cardiac inflammation took place at the very commencement of the disease, and simultaneously with the invasion of the joints.[55] [Footnote 52: _Lib. cit._] [Footnote 53: Raynaud, _Nouveau Dict. de Méd. et de Chir._, t. viii. 367.] [Footnote 54: _Lib. cit._, pp. 77-278.] [Footnote 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's[57] 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's[61] case appear to have been examples of ulcerative {34} 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. Goodhardt[62] has lately insisted upon the tendency of ulcerative endocarditis to appear in groups or epidemics, but the evidence is not conclusive. [Footnote 56: _Archives Médecine_, vol. v., 1881; _Trans. International Med. Cong._, vol. i. 341.] [Footnote 57: _Clin. Soc. Trans._, xiii. 227.] [Footnote 58: _Brit. Med. Jour._, i., 1880, 798.] [Footnote 59: _Medical Record N.Y._, 24th Sept., 1881, 361.] [Footnote 60: _Canada Med. and Surg. Journ._, vol. xi., 1882, 1, and _ib._, vol. ix., 1881, 673.] [Footnote 61: _Lancet_, ii., 1882, 976.] [Footnote 62: _Trans. Path. Soc. London_, xxxiii. 52.]