In a small minority of the cases the medicine, although well borne, ap pears to exercise no influence upon the disease, and even when it lowers the temperature and subdues the joint affection, it seldom prevents the oc currence of cardiac or pleural inflammation. The first signs of pericar ditis may be noticed when the patient appears to be under the influence of the remedy ; and I cannot say that in any case the course of the peri cardial disease has appeared to me to be shortened by the use of the sali cylate. Still, if only for its influence in reducing temperature and check ing articular inflammation, the drug would be a most valuable one, and we should not be doing our duty to the patient if we neglected to employ it.
In cases where the salicylate cannot be used, we may adopt the alkaline treatment, giving bicarbonate of potash in ten-grain doses every three or four hours. If thought advisable, the bicarbonate may be combined with quinine ; or we may prescribe a mixture of quinine with iodide of potas sium, as recommended by Dr. Greenhow. The objection to the alkaline plan of treatment is that it encourages the tending to anemia. It should therefore be supplemented by the early administration of iron when the joint pains have subsided. The method of treatment advocated by Dr. H. Davis, which consists in encircling the affected joint with a thin line of blistering fluid is a painful proceeding and ill-suited to young patients. The best local application is a thick layer of cotton wool, with a firmly ap plied flannel binder.
If there be much pain in the joints, a small close of Dover's powder can be given at night (gr. ij.—iij. to a child of four or five years old). Chloral must not be used during the administration of the salicylate, as it also has a depressing effect upon the heart.
Hyperpyrexia is not common in cases of rheumatic fever in children, and, indeed, it is difficult to say what degree of elevation of temperature can in an ordinary case be accounted hyperpyrexia in a child. An injurious , amount of fever is usually accompanied by symptoms of mental disfurb ance such as are characteristic of the so-called " cerebral rheumatism." If these are absent, it is unnecessary to attempt to reduce the temperature by baths ; unless, indeed, the pyrexia persist and seem to be injuriously affecting the patient's strength. I have never seen a case of rheumatic fe ver in a child in which I have felt it necessary to employ cold.
The diet in acute rheumatism must be simple. While the fever per sists the child should take nothing but milk and fresh-meat broths, with a little dry toast. When the temperature falls, a more generous diet may be allowed ; but for some time attention should be paid to the quantity of fermentable matter, such as starches and sweets, taken by the child. The appearance of lithates in his water is a sure sign that some modification in his diet is required.
Directly the existence of pericarditis is ascertained, a blister should be applied over the pracordial region without loss of time. I prefer the blistering fluid for this purpose as most certain in its action, and use it to quite young children. It is of extreme importance to check the peri cardial inflammation early, and there are no means at our command so efficacious for this purpose as a blister. In many cases the effusion begins
to disappear as the blister rises. If there be much effusion, and the joint affection have subsided, I am in the habit of giving large doses of the io dide of potassium, alone, or with the tartrate of iron. The iodide is in my opinion of great value in removing serous effusions, if given in full doses. To a child of five or six years of age I give ten grains of the io dide three times a day, and have never seen ill effects follow its employ ment. On the contrary, its value in causing absorption and restoring the natural state of the membrane has appeared to me to be very decided.
In endocarditis, also, blistering should be employed ; and if the tem perature has fallen, iron and quinine should be prescribed. The same tonic treatment can be adopted in cases of pericarditis after absorption of the effusion, for the patient is usually left anaemic and weak from the at tack, especially if he have been treated with the salicylate of soda. In all cases where the disease has been complicated with endocarditis it is ad visable to keep the child in bed as long as possible ; and even when he is al lowed to get up it is wise to enforce the utmost attainable quiet. In these cases the heart is more likely to recover itself if its action be not excited ; and, indeed, judicious care during convalescence may largely influence the future well-being of the patient. Complete rest moderates the heart's ac tion, and allows time for the healthy removal of inflammatory products from the valves. If such products become organized, they contract the tissues and cause puckering of the valves, with all the evils which the resulting hindrance to the circulation must inevitably entail.
If suppuration in the pericardium is suspected, the sac should be care fully punctured with a hypodermic syringe in the fourth or fifth interspace, near the left edge of the sternum, to make sure that the fluid is purulent. If it prove to be so, the question of evacuating the contents of the peri cardium must be considered. Professor Rosenstein has reported an interest ing case, in a boy of ten years of age, in whom recovery took place after the sac had been emptied. The pericardium was opened by incision in the fourth space, near the sternum, and after the pus had escaped, two drain age-tubes were passed into the wound, and antiseptic dressings were em ployed. This form of pericarditis is so fatal that the operation should be decided upon if the state of the patient offer the slightest prospect of its success.
Muscular rheumatism, whether it affects the abdominal wall or the muscles of the neck, must be treated with stimulating applications and with warmth. A good mercurial purge to relieve the bowels is useful.
In cases of chronic joint pains affecting children who are old sufferers from rheumatism, it will be often necessary to change the conditions under which the patient has been living. Removal to a warm dry air will often do wonders. Great attention should be paid to the action of the skin and kidneys. Five or six grains of bicarbonate of potash, with an equal quan tity of citrate of iron, given three times a day, will be found of service. Fermentable matters and acid-making articles of diet should be taken with moderation.