The diagnosis of ulcerative endocarditis has been already sufficiently ex plained. If we find that a child, who has lately suffered from an attack of acute rheumatism with endocarditis, remains feverish, with rapid elevations and depressions of temperature, such as are characteristic of suppuration ; if he pass quickly into a typhoid state with dry brown tongue, loss or ap petite, hurried breathing, and signs of great prostration, we should sus pect the presence of this complication ; and if we find evidence of embol isms in special organs, our suspicions are sufficiently confirmed.
Prognosis.—The immediate prognosis of acute rheumatism is seldom otherwise than favourable. Even the existence of endocarditis and inflam mation of the pericardium cannot often be regarded as giving rise to any fear of immediate danger. Still, it is well not to speak too positively in predicting a favourable issue to the illness. In acute rheumatism—even in the mildest cases—there is a tendency to hyperinosis ; and the rapid for mation of a clot in the right ventricle of the heart or in the pulmonary artery may be a cause of sudden death. In some instances this distress ing accident happens quite unexpectedly in a case which is running a fa vourable course, and may even occur at a late period of the disease after convalescence has seemed to be established. Again, in rare cases, pericar ditis is a cause of death. When the effused fluid is or becomes purulent, the danger is great ; and few such cases recover.
The ultimate consequences of an attack of rheumatic fever may be very serious, for the large majority of cases of heart disease can be referred to this cause. But, as already remarked, the mechanism of heart-murmurs is so various, that the mere existence of a blowing sound at the apex of the heart is no indication in itself that serious consequences are to be ap prehended. If the child be seen during an attack, or while the murmur is still recent, it is impossible to speak with certainty as to the gravity to be attached to the phenomenon. If, after a time, we discover signs of di lated hypertrophy of either ventricle, with displacement of the heart's apex, and accentuation of the second sound at the pulmonary cartilage, we may positively assume that serious incompetence exists of the mitral valve.
Enclocardial murmurs arising during an attack of rheumatism in chil dren sometimes disappear. It is probable that in all these cases the mor bid sound was generated by other mechanism than valvular. incompetence, for I have never known the auscultatory sounds to become healthy except in cases where the heart's apex has retained its normal situation.
A little boy, aged eighteen months, with sixteen teeth, was brought to me in November, 1874. A few months previously he had seemed to have pain and stiffness in some of his joints, and had been a little feverish. Since that time he had been subject to palpitations which were sometimes violent. On examination I found a loud basic systolic murmur conducted
to the second right cartilage, and at the apex a less loud mitral mur mur. The apex-beat was normal. In March, 1875, I saw the child again. The apex-beat was still in normal site. The heart-sounds were a little muffled to the ear, although no murmur could be heard at either the base or the apex ; but on this occasion no attempt was made to excite the heart's action. The patient was seen for the third time in March, 1881. He was now nearly eight years old, and of average height for that age. Although rather thin, he was stated to enjoy good health, and never complained of palpitations or of breathlessness. The position of the apex-beat remained unaltered. The first sound was muffled, and after the boy had been made to run round the room, a faint systolic murmur was developed at the apex. It could not be heard at the angle of the scapula.
In this case the basic murmur disappeared, and that at the apex be came so indistinct that it. could only be detected by exciting the heart's action. Whatever may have been the cause of the abnormal sounds first heard, they were apparently the consequence of rheumatism. Still, it seems certain that there could have been no organic lesion of valve, for in the course of nearly seven years no alteration in the nutrition of the heart had taken place.
Treatment.—A child the subject of acute rheumatism must be kept in bed ; the inflamed joints must be wrapped in cotton wool, kept in place by a firmly applied flannel bandage ; and the chest should be also enveloped in the same material. A mercurial purge should be given to produce free action of the bowels ; and salicylate of soda should be administered with out unnecessary delay. Children, as a rule, bear this remedy well. It is exceptional to find any ill effects resulting from its employment. For a child of five years old, ten grains of the salt may be given every two or three hours with tincture of orange peel and glycerine. Within two or three days, sometimes within a few hours of beginning the treatment, the temperature falls, the pulse becomes less frequent, and the joint symp toms are moderated. The pulse usually loses in strength as well as in frequency ; and the depression induced by the action of the drug upon muscular fibres of the heart is sometimes so great that its administra tion has to be supplemented by the free use of stimulants. This effect of the remedy is, however, less common in children than it is in the adult, and I have rarely been obliged to discontinue its use for this reason. It sometimes causes distressing vomiting, and occasionally excites epistaxis which may be obstinate. If, on account of any of these accidents the treatment has to be suspended before the disease is completely subdued, the temperature often rises again, and the joint affection may return.