Torticollis (stiff-neck) is sometimes a consequence of rheumatism. The disease may affect the muscles, especially the sterno-mastoid ; or may at tack the fibrous ligaments uniting the vertebrae. The nervous system, too, may suffer. Neuralgia has been noticed in some children ; and paralysis of the muscles of 0113 side of the face may be produced by rheumatic in flammation of the sheath of the facial nerve at its point of exit from the bone. Moreover, there is an evident connection between rheumatism and chorea. This important subject will be considered elsewhere (see Chores).
A peculiar manifestation of rheumatism is sometimes found in chil dren. This was first noticed by Meynet, and is characterized by swellings varying in number and size which appear in the tendons and their sheaths, and in other fibrous structures which lie close under the skin. Thus they are seen around the patella and the malleoli ; on the spinous processes ; on the temporal ridge, and on the superior curved line of the occiput. They are very hard ; are accompanied by no redness, tenderness, or pain ; are sometimes movable ; and disappear after a time spontaneously. They are composed of small masses of loose fibrous bundles, and are very vas cular.
A little girl, nearly ten years old, was under my care in the East Lon don Children's Hospital for an attack of rheumatic fever complicated with chorea. She had a harsh systolic murmur at the apex of her heart, which evidently dated from a previous attack of endocarditis ; but the apex-beat was not displaced, nor were the normal limits of the heart's dulness ex tended. In this child fibrous nodules were found on the spinous processes of the vertebrm, the prominences of the scapula, the head of the radius, the tendons in front of the right ankle, and the back of the right hand. The nodules varied in size from a split pea to a large marble ; they were not tender, and the skin over them was not adherent. While the child re mained in the hospital her temperature never at any time rose above The swellings gradually diminished in size, and by the end of the month had almost completely disappeared.
The duration of the rheumatic attack is much longer in some children than in others. It may be variously estimated according to the method upon which the reckoning is conducted. If we take into account merely the joint affection and the general symptoms, the disease may be considered over in a few days. A child may be taken with high fever, and complain
of pain in one or other of his joints, which is found to be red, swollen, and tender. In twenty-four or forty-eight hours the articular inflammation may be at an end and the temperature normal. But it does not follow that the disease is over ; and if we at once begin to treat the child as a convalescent, we may find reason to regret our precipitation. Serious in flammation of the pericardium and lining membrane of the heart is quite compatible with a normal temperature ; and these internal lesions may be only beginning when the external signs of the disease are on the wane. As it is only in exceptional cases of rheumatic fever that the heart does not suffer, and as the mildest attack of pericarditis is seldom over before a week has gone by, eight or ten days must be considered the earliest period at which convalescence can be said to begin.
In other cases, if there are frequent relapses, the disease may be pro longed for many weeks, the inflammation leaving joints and returning to them with wearisome repetition, and the pericardial inflammation waxing and waning with similar persistency. In this way an attack may be made to last six weeks or two months. It is, however, only right to say that since the introduction of the salicylates these cases are much rarer than they used to be.
Although the joint affection in rheumatism is usually an acute disease, and ceases when the attack is at an end, yet this is not always the case. Children with strong rheumatic tendencies, and who have had several at tacks of rheumatic fever, may complain of wandering pains in the back, neck, and loins, and of transient discomfort and stiffness in a joint from time to time, especially in the variable seasons of the year, without having to take to their. beds. In such patients there is general impairment of health, appetite is poor, and nutrition is unsatisfactory. The child is often excessively nervous, sleeps badly at night, and is changeable in tem per. Dr. West has connected these symptoms with the lithic acid diathe sis. There is no doubt that such children are subject to sandy deposits in their urine, and to abundant secretion of urea.