dental to childhood alone, but rather with the manifestations of disease in children, with the special peculiarities of disease which the period of childhood induces.

Rheumatism offers an excellent illustration of the case in point. Its clinical manifestations, as seen in childhood, are very different from those of adult life. In the first place, the arthritic symptoms are not nearly so well marked. In many cases we do not have the sudden onset with high fever, red, swollen, and intensely painful joints and the severe constitutional depression that form the symptom-complex in adults. The joints may not be greatly reddened and swollen. Indeed it is a point worthy of special insistence that the pain is not always referred to the joints. at all. We have come to know, for instance, that the so-called "growing pains" of children are frequently rheumatic in origin, and to appreciate, furthermore, that at times they are the only rheumatic pains from which children suffer. Though arthritis is at its minimum, endocarditis is at its maximum in the rheumatism of childhood. As a matter of fact, the modern view inclines to the belief that heart-lesion is not to be regarded as a complication of rheumatism in the child, but as one of the manifestations. The close association of rheumatism, endocarditis and chorea has been recognized for a long time, and by many are now regarded as merely different phases of the same morbid process. Nor is it to be forgotten that rheumatism need not necessarily precede the other affections in point of time, nor must all three conditions be present in a given case. As Cheadle has put it, “Any one of the phases may be absent, one only may be present, or two, or all three. The different manifestations, again, may occur not only in any order and combination, but separated by varying intervals of time; following one another in quick succession, or some appearing months or years after the rest. Thus an endocarditis or a pericarditis, or a chorea, may occur first and alone, the joint affection long after."

In addition there are certain symptoms of rheumatism in childhood that demand special notice. Peliosis rheumatica is quite common in childhood. In many cases the child sickens with what appears to be an ordinary tonsillitis. After a varying

In a case

interval, usually measured in days, the characteristic purpuric rash develops, usually about the extremities. The spots are usually purple in color, of variable size, most often tender on pressure. In some cases the rash becomes generalized. Arthritic symptoms may develop, but need not. recently under treatment in the children's ward of the Jewish Hospital, the tonsillitis and rash with the usual febrile movement and constitutional disturbance were present without arthritic symptoms. The history of the case showed that the boy had had several distinct attacks of articular rheumatism. Under the salicylates improvement was rapid. This condition is in all probability to be regarded as a "rheumatic equivalent," and its occurrence in a given case affords strong presumptive evidence of a rheumatic diathesis.

Rheumatic nodules also occur more often in the rheumatism of children than in that of adults, although in this country they are rare in either form. These nodules, first described by Barlow in 1881, are subcutaneous masses of fibrin, cells and fibrous tissue, varying in size from a pin-head to that of a small bean. They are most apt to occur over the malleoli, at the margins of the patella, or along the extenser tendons of the hands, fingers or toes. There is at the present time in the Jewish Hospital a boy 12 years of age suffering with articular rheumatism, who presents an exquisite picture of this rheumatic manifestation.

This case is of more than ordinary interest, and it therefore may be permissible to detail a few points of the history. The boy presents various manifestations of late hereditary syphilis, the specific dactylitis being especially well marked. The accompanying photograph, unfortunately not good, gives some idea of this manifestation. For two years this boy has been subject to attacks of acute articular rheumatism. On admission, there was moderate fever, swelling and pain of both ankles and wrists. Rheumatic nodules were particularly distinct along the extensor tendons of the right hand. The heart was markedly dilated, the dulness extending two fingers' breadth beyond the midclavicular line on the left, and beyond the sternal margin on the right. A double murmur was heard at the apex. At the junction of the

third rib with the sternum on the left side was heard a typical pericardial rub. Here we had the combination of arthritic manifestations, with endopericarditis, as we frequently find it in these cases.

Another symptom of rheumatism in children, often of diagnostic importance, is recurrent epistaxis for which no local cause can be found. The mechanism of its production is not clear, and yet the association occurs so frequently that it cannot be a mere matter of coincidence. Last year Phillips reported 10 cases of epistaxis all associated with rheumatism. The occur

rence of so-called idiopathic nose-bleed in children is therefore frequently suspicious.

While the diagnosis of rheumatism in the adult is, as a rule, not a matter of difficulty, its recognition in childhood is not always easy. This is because of its atypical onset and course. Thus the onset of an endocarditis, which, as we have seen, may be the initial phase of the disease, is often very insidious.

Even the most careful examination may fail to reveal anything wrong with the heart other than a slight weakness, some irregularity and greater rapidity of action, though sometimes a faint murmur may be heard. The general constitutional symptoms of languor, depression and anorexia are not at all specific. It is in these cases that careful observations of the temperature,

continued over periods of time, are of great value. Continuous fever with slight remissions, even though of comparatively low degree, not explainable by the other definite infection, is one of the most reliable signs of beginning endocarditis that we have. Indeed, in an article entitled "Endocarditis and the Use of the Thermometer in Its Diagnosis," Brunton goes so far as to say, “If you find a murmur at the heart, or even in cases where you can find no murmur, if you find a temperature which runs a course much like that of quotidian ague in a case where you can. trace no malaria, and where you can find no indication of suppuration, it is very likely indeed to be a case of endocarditis."

Again it is to be remembered that the chorea is not necessarily of the clear unmistakable type which allows a diagnosis to be made at sight. Very frequently the child is simply "nervous,' awkward at play or at table, usually restless or irritable, showing only indications now and then of the characteristic choreic move

ments.

Of course, when all is said, in most cases the diagnosis is not difficult. But, as Holt has put it, the disease is more frequently overlooked than confounded with other diseases. In doubtful cases especial attention should be paid (a) to the family history, (b) to the previous history of the patient as regards slight joint stiffness without swelling, growing pains, nose-bleed, frequent attacks of tonsillitis and erythema, (c) the examination of the heart for signs of endo- or pericarditis and (d) the temperature. Careful search will sometimes reveal the presence of the tendinous nodules.

It must not be forgotten either that in the rheumatism of childhood, even in marked cases, we do not have the successive involvement of many joints as we do in adults. In children we very frequently have very few joints involved, and in many cases, certainly not gonorrheal in origin, (though gonorrheal rheumatism is not rare in childhood), but a single joint is involved. With reference to prognosis, it need hardly be said that the rheumatism in itself is rarely dangerous. The danger lies in cardiac manifestations. Unfortunately, one attack greatly predisposes to subsequent ones, and so the heart, which at first may escape, may

in a recurrence become affected. Prophylaxis plays an important rôle in the care of rheumatically inclined children. In cases in which the family history shows the existence of rheumatism, the predisposed child should be carefully watched. The indefinite symptoms before referred to demand attention; exposure to damp weather, rather than to cold weather, must be avoided as much as possible, and such definitely rheumatic symptoms as growing pains, recurring torticollis, etc., should receive appropriate treatment. In the line of prophylactic treatment too comes proper attention to the condition of the child's throat. The existence of adenoid vegetations and of enlarged tonsils especially, is a matter of concern, inasmuch as the tonsils doubtless form the port of entry for the rheumatic virus in many cases.

With reference to the actual management of these cases, it is well to remember that rheumatism in childhood is apt to extend over a long period, frequently measured by years. Crandall has expressed this idea very aptly in discussing the management of "rheumatic children" rather than simply the question of rheumatism in the child.

The relation of diet to rheumatism is still a question sub judice. While the uric acid theory of causation held sway, it was believed that nitrogenous foods were to be strictly eliminated from the dietary. The prohibition extended even to animal broths and eggs. It appears certain now, that rheumatic children do best upon a generous dietary, in which the special limitations are to be applied to the sugars and starchy foods. Malnutrition is frequently a factor to be considered in these cases, anemia is almost the rule. Under the circumstances, a liberal, nourishing diet, with moderate amounts of the more easily -assimilable meats, with plenty of green vegetables, will be found to meet the indications most often. Special mention should be made of milk, which should be taken in large quantity.

Rheumatic children should wear flannel underwear the year round, its weight being varied according to season. Its value in diminishing the danger of chil! is fully established. While exposure to cold itself is to be avoided when possible, it should be remembered that damp weather, with cold east winds, with the