Many authorities emphasise the importance of a minute examination for any septic focus as pyorrhoea, otitis, enlarged tonsils, etc., which should be radically dealt with in order to minimise the liability to further attacks. It is obvious that the greatest care as regards clothing and exposure to cold and damp should be always maintained.
Acute Rheumatism in Children.—Great advances have been made in the diagnosis of this condition, which was generally overlooked in former years. Though the disease is to be considered as identical with the acute affection of adults, there are several well-marked differences to he observed which have their bearing on therapeutics. The most important of these is the far greater frequency of serious cardiac manifestations and the minor part which the arthritic manifestations play in the clinical picture, so that the disease in children has been termed " Acute Carditis," or " Cardiac Rheumatism." Not only do the endocardium and the pericardium suffer severely, but the heart muscle is rapidly affected. as seen in the acute dilatation of the left ventricle frequently following the rapid myositis caused by the rheumatic toxins, and these grave conditions may exist when the only joint symptoms may be so slight as to he mistaken for the so-called " growing pains " of childhood. Sub cutaneous nodules may be found present in more than 5o per cent. of such cases.
Absolute rest is even more essential than in adult cases, and though the joint pains call for little interference, it seems advisable to commence the routine administration of Salk);laws, but these should be always combined with full doses of alkalies. In the presence of severe cardiac weakness the salicylates cannot be pushed, but moderate doses (5 grs.)
of Saloquinine or Rhcumatin may be administered in combination with Strychnine.
For the relief of cardiac pain, which is often severe, a thick layer of the Cataplatsma Kaolini laid over the entire cardiac area may be used. The warm-water rubber bottle, the ice-bag and absorbent wool each has its advocates. In marked dilatation of the ventricle, half a dozen leeches may be applied and a smart saline purgative given by the mouth and a dose of Strychnine hypodermically. At a later stage Digitalis or Strophanthus will be indicated. It will often be necessary to resort to a moderate amount of Morphia to quiet distress and promote sleep, and it should be combined with a full dose of Sodium Bromide.
Pericarditis may require tapping. (See under Pericarditis.) Menzer's Serum and Vaccine treatment have been also recommended in the treatment of the acute rheumatism of childhood.
As already stated, the rest should be prolonged into several months in order to prevent permanent damage and deformity of the cardiac valves, and during this stage Iodides may be advantageously employed.
Much importance has of late been attached to the part played by local septic conditions of the mouth, naso-pharynx and tonsils in the acute rheumatism of childhood, and Schichhold even recommends the total enucleation of the tonsils during the attack. It certainly should be the rule to deal radically with these and with adenoids and suppurating gums and carious teeth during or after convalescence in order to diminish the risks of further rheumatic seizures.
The child should be enveloped in warm woollen underclothing, and should wear thick-soled boots and be long protected from the risks of cold and damp.