Course and Prognosis. Most cases of polyarthritis in children get well quickly and completely; on the other hand, it may be with a defect of the cardiac valves. Relapses are frequent in children, and it is not uncommon to have endocarditis develop during a second or third attack, if a previously existing lesion should grow worse. Death occurs almost. without exception from severe cardiac complications; particularly pericarditis, but occasionally from multiple emboli. In rare cases swelling and stiffness may remain in some of the joints. Re peated relapses may cause a transition into the chronic articular variety.
So far as life is concerned, the prognosis is more favorable in chil dren than in adults. It is, however, entirely dependent upon the severity of the heart complications.
Diagnosis.—The diagnosis of acute articular rheumatism is usually readily made. Nevertheless there are cases in which difficulties occur, and where a. false diagnosis might. be fatal. This applies especially to those forms of rheumatic arthritis in which prompt surgical interfer ence is indicated, as in the cases of septic and pneutnococcic arthritis. At any rate the possibility of the presence of a rheumatoid condition must be considered, and of course one must exclude scarlet fever and gonorrinea.
The characteristic symptoms of pneumococcic arthritis will be described below. The diagnosis of rheumatic arthritis is based in gen eral on the migratory attacks in the joints, the character of the in flammatory process, the polyarticular localization and the beneficial influence of salicylate therapy. Endocarclitis, if present., it is true, does furnish in the case of rheumatoid conditions, a most valuable and an indisputable element. Cases of hereditary syphilitic joint affec tions deserve special attention. They follow a subacute course and, attacking the two knee-joints symmetrically, are often incorrectly ding nosticated. Further details regarding these cases will be given on page 500. In a case of syphilitic osteochondritis, only a careless exami nation can possibly lead to a wrong diagnosis.
From a differential standpoint it may be said that an atypical at- tack of articular rheumatism, beginning with severe pain in the hips, may at first impress one as a severe case of suppurative coxitis. In one case under my observation the diagnosis of sciatica was also erroneously made. Sometimes the distinction between spinal caries.
or beginning retropharyngeal abscess and rheumatism of the cervical portion of the vertebra] column may create difficulties. The presence of osteomyelitis, too, may occasionally appear probable. An accurate local examination as well as the course of the disease will readily clear. up the diagnosis.
In little children and infants who, by the way, are more frequently subjected to all kinds of rheumatoids than to true acute articular rheu matism, infantile scurvy must occasionally be differentiated from poly arthritis. Careful examination of the gums and urine and localization of the pain in the limbs will prevent a wrong diagnosis. Articular swelling, which sometimes occurs after the injections of a curative serum, is di rectly traced to its cause by a knowledge of the history. It must again be stated that an abortive course of articular rheumatism is often called growing pains, and only later on, because of an enclocarditis or chorea. developing, is it correctly diagnosticated.
Prophylaxis is especially important in children who either have already had an attack of articular rheumatism or chorea, or who are de scendants of rheumatic families. Dry and healthy habitations and avoid ance of exposure to cold or wetting are very essential factors. Often the wearing of woolen or merino undergarments is to be recommended. A hardening process by means of hydrotherapy carefully begun under systematic medical guidance is particularly beneficial.
Treatment.— Two conditions must always be complied with : rest. in bed until a11 manifestations cease and a constant regulation of the temperature of the room at 14°-15° R. (62°45° F.). Every opportunity to acquire a cold subjects the patient to the possibility of a relapse and a prolongation of his sufferings. During nursing, and the chang ing of linen, etc. this possibility ,must be carefully watched, as the profuse perspirations which are present in the disease, or possibly also the salicylate treatment, may enhance the danger of chills and colds. The bed should stand in the most protected part of the room and above: all not close to a cold wall. Woolen garments, even when in bed, are often of advantage. Warm but not too heavy bed covering is important, and should be the special care of the nurse, particularly with the younger children, who are apt to uncover themselves.