ground covered with slush, is especially favorable for the development of rheumatism. For the actual attack the salicylates, in combination with bicarbonate of soda, offer the best plan of treatment. In order to get good effects from the salicylates, the quantities used must be rather large. While it is doubtless true that these drugs are somewhat depressing to the heart, it is just as true that children ordinarily stand proportionately large doses. When the case can be carefully controled, the use of large amounts at the outset so as to mass the effect, is of decided advantage, though this plan of treatment demands watchfulness on the physician's part. The salicylates certainly have a marked analgesic effect, even though there be some doubt as to their value in preventing cardiac trouble. Local applications to the joints, if they be inflamed, are not always necessary. Simple wrapping of the joints in cotton batting is usually sufficient, though at times it is well to immobolize the joints by splints. Occasionally, the local application of 2% salicylic acid ointment has seemed to give some relief. The rapid development of severe anemia is one of the characteristics of rheumatism in childhood, and this needs to be met as soon as possible by the administration of ferruginous tonics. Indeed, as a matter of fact, the treatment of the acute attack itself is nearly always very simple. The point to be remembered is the necessity for keeping these children under constant observation for long periods of time. The danger of cardiac involvement, grave under any circumstances, is heightened by the tendency to frequent recurrences. The after-treatment is, therefore, of importance. One very necessary factor in this after-treatment is rest. The child should be kept abed for some time after the subsidence of all acute symptoms, even though an examination of the heart be negative. Prolonged rest, which means absence of cardiac strain, is one way of preventing heart lesion, a way not always successful of course, but a method of treatment worth trying in any case. On the theory that rheumatism is of bacterial origin, and that the salicylates have a bactericidal, or antitoxic effect, it has been recommended to administer small doses of salicylates at intervals (say during one week each month) for long periods of time. This is to be done even where there are no distinctly rheumatic manifestations in the hope of warding off attacks. This line of treatment has proved successful in a number of cases. But after all, the therapy of rheumatism in childhood is not a matter of drugs alone. Proper clothing, regulation of exercise, avoidance of exposure, prevention of anemia, and lastly, (and perhaps most important) attention to the condition of nutrition by the enforcement of a properly regulated diet will be found to be our most reliable aids in the management of a condition always troublesome, and frequently serious. DISCUSSION Dr George E. Malsbary, Cincinnati: Rheumatism is a term that is still used to cover a number of diseases and to act as a cloak to hide many failures in diagnosis. The time will probably come when we will no more think of making a diagnosis of rheumatism than is the intelligent physician at the present time satisfied with a diagnosis of neuralgia. Rheumatism has the same derivation from the Greek as catarrh, and was used by the old humoral pathologists to cover almost all diseases which were attributed to a humor flowing through the body. About the time of Ballonius, 1600, the term "catarrh" became confined to affections of mucous membranes, and "rheumatism' was limited to the painful diseases of the bones, joints, and structures other than mucous membranes that were not known to be due to any special or specific cause. Later investigations have isolated gout, arthritis, trichinosis, syphilis, tuberculosis, rickets, and osteomalacia. The term "rheumatism" is still used to cover at least five distinct affections: Acute articular rheumatism, Chronic articular rheumatism, Some work presented before the American Medical Association, at New Orleans, last month, would seem to indicate that possibly we may take from this list the cases of chronic articular rheumatism and place them among the nervous affections. In either event they must be regarded largely as expressions of toxemia. The cases of nodular rheumatism are better classified are arthritis deformans. "Gonorrheal rheumatism" is at the present time a convenient but unnecessary term. Such cases are either cases of gonorrheal arthritis, being due to an invasion of the joint by the gonococcus, or they are cases of septic arthritis due to the septic microorganisms and occurring as a secondary infection in the course of or after gonorrhea. The term "muscular rheumatism" is not so much used as formerly. Trichinosis is no longer considered a muscular rheumatism. Many of the cases still classified under this term are due to trauma, whereby muscular fibers are ruptured. Many cases are attributed to cold and exposure, and it has been proposed to substitute the term "myalgia" for muscular rheumatism, a change of doubtful utility, except from a philologic standpoint. The only requirement of a disease to be admitted to this classification is that it shall be characterized by pain confined to the voluntary muscles, not known to be due to any special or specific cause. Thus the temptation is afforded to use this term as a sort of dumping ground for imperfect diagnosis. The form of rheumatism most frequently found in children is that commonly known as acute articular rheumatism. In children it is important to rule out especially rickets and syphilis before making a diagnosis of rheumatism. The essayist has referred to the arthritis being at a minimum in the rheumatism of childhood, whereas the endocarditis is at a maximum. This would suggest the possibility that such cases are septic in character. Indeed, it is probable that acute articular rheumatism is in many instances an expression of toxemia, due to the absorption of toxins. Such cases may be observed, for instance, in the presence of a follicular tonsillitis, the toxins being formed by the microorganisms in the crypts as in a test-tube. Not infrequently the attacks of articular rheumatism are preceded by an angina. In one marked case of rheumatism, I was able to jugulate the disease by the treatment of the throat. Again, I have removed the diseased tonsils, in old cases of follicular tonsillitis, and have been rewarded by a disappearance of an accompanying rheumatism. I do not mention these experiences as unique ut rather because they are becoming so common. Such cases of rheumatism must be regarded as toxic in character, and it is logical that the disease should disappear after the removal of the focus of disease from which the toxins are being absorbed. The focus of infection need not necessarily be in the tonsil but may be in some other recess of the body. The importance of finding and removing the focus of infection in such cases is obvious. In some instances acute articular rheumatism may be regarded as a modified sepsis. In such cases a streptococcus of a low degree of virulence is not infrequently to be found. At the present time I am very much interested in the use of the antistreptococcus serum in the cases of rheumatism in which this microorganism is demonstrated. Dr G. A. Hermann, Hamilton: I would like to ask the Doctor if he has ever had a case resulting in paralysis of the lower extremities. I had a child under my care who had an attack of measles who ten days after this attack developed a case of rheumatism. I put the child on the salicylates for a month when the child developed a paralysis of the lower extremities and is still going around in that condition. The child is four years of age and apparently healthy. Dr William D. Stewart, Toledo: In the majority of instances I think the condition rather than being a rheumatic state, such as we find in the adult, is due to malnutrition, that is to say as we find it in children. I do not deny that we have rheumatism in children, but in my experience I have not been encountering these conditions frequently, but I do often run across a condition of malnutrition which may produce symptoms somewhat similar to rheumatism. We also find the symptoms as described by the Doctor occurring in rickets and scorbutus. Hence if we direct our energies toward the correction of the malnutrition in many instances we will find that the so-called rheumatism will disappear. It Dr H. A. Beeson, Leesburg: In the treatment of the acute and subacute rheumatism we rely upon the salicylates for the reason that the treatment is almost specific. relieves the pain, acts freely on the kidneys and the emunctories generally, and therefore we use it, and do not attempt to relieve the pain with something else. Dr Comegys, deceased, of Cincinnati, was of the opinion that he had a form of the salicylate of soda which was more prompt, active and useful than any other, and he made it as he used it. He called it the "nascent salicylate of soda." His formula was about this: Soda salicylate one drachm, soda bicarbonate two drachms, glycerin two ounces and aqua destillata q. s. to make six ounces. He dissolved the bicarbonate of soda in the menstrum first, then added gradually the salicylic acid. As you know effervescence will be very prompt and strong. Adding the acid gradually you will have, when the solution is complete, a very pleasant syrupy solution of salicylate of soda. Of this he recommended that there be given from one teaspoonful to a tablespoonful every three hours. This is certainly a most effective remedy for acute and subacute rheumatism, and I would recommend it heartily. Dr Alfred Friedlander, Cincinnati, closing: The use of antistreptococcic serum would logically follow, if we believe rheumatism a form of septicemia, but personally I have had no experience with it. With reference to the paralysis following rheumatism, it is to be remembered that neuritis is very common after the acute infectious diseases of children. One need only refer to multiple neuritis, or to acute anterior poliomyelitis. It is certain that there are many cases that look like rheumatism which are not. As for malnutrition in children, while it is, of course, enormously common, I hardly believe that it will cover all cases of rheumatism. I certainly do not think that all cases of rheumatism can be classed as simple malnutrition. Many cases of rheumatism show marked evidences of malnutrition. Many cases are combined with rickets and scurvy, but they are genuine cases of rheumatism for all that. It is not to be forgotten that rheumatism occurs at all times of life, and in many forms. Regarding salicylate of soda, I would say that I have had the best results from the salicylate prepared from the natural oil of wintergreen, as I find that the stomach of children is much less easily upset by this preparation. |