By F.W. Winter, M.D.
The selection of this topic was made from the fact that frequently too little attention is given by physicians to the subject of rheumatism in children, especially since it manifests itself in different forms, and these different manifestations extend over such varying periods of time that we do not see the relation existing between them, ascribe them to temporary superficial causes merely, and thus fail to recognize their true import, and before we are aware of it the integrity of the heart is involved and a permanent lesion of greater or less degree has become established and which undoubtedly is the source and cause of so many cases of sudden death from heart failure in later life.
Clinically authors give us three classes of rheumatism: First, articular rheumatism; second, rheumatism of other organs, external and internal; and thirdly, general or non-circumscribed rheumatism. The second includes some of the skin affections, the vascular apparatus, the respiratory and digestive tracts, and the muscular and nervous systems. These may all be recognized somewhat readily, but in the general or non circumscribed rheumatism. The second includes some of the skin affections, the vascular apparatus, the respiratory and digestive tracts, and the muscular and nervous systems. These may all be recognized somewhat readily, but in the general or non circumscribed instances the symptoms are not so apparent, yet, if fully investigated and rightly interpreted, cannot otherwise but be attributed to and classified as of rheumatic origin.
As to the causes of rheumatism heredity of course stands at the head. Family history develops this fact, and doubly so when both parents have been afflicted. Next to this is placed exposure to sudden changes and extremes in temperature or to a prolonged chilling or wetting, especially when the body is in a heated or exhausted condition from overwork. And who lay themselves open to these conditions more than children with their naturally irrepressible roving and romping disposition?
But just what the pathological changes thus brought about in the system are and their causes is still something or an open question and different theories are being advanced for their solution, such as the neurotic, the infectious, and the lactic and uric acid theories, some even also ascribing them to miasma tic and parasitic origins. The preponderance of evidence and the commonly accepted theory, however, now seems to be that the acute manifestations of rheumatic fever are the result of a specific infection. Be that as it may, at least a striking and close relationship has been found to exist between rheumatism and endocarditis, and the latter is now generally accepted as infectious in origin.
This conclusion is arrived at from its occasional epidemic appearance, its occurrence as a house disease and from the post mortem examination of cases of articular rheumatism, As grounds for such belief, the tonsils are cited as the point of evidence of the infection, since an inflammation of the tonsils is oftentimes the in tail and may be the only symptom of an attack of rheumatic fever. On the other hand, attention has been called to the relation of scarlet fever to acute rheumatism as worthy of note. There is a similar painful swelling of the joints often following the wake of the former, and there is also oftentimes an accompanying or consequent endocarditis. Whether the scarlet poison induces the latter two, which cannot be distinguished from those of acute rheumatism, or simply excites to rheumatic inflammation, is open for debate, though preference is given to the former opinion.
Aside from the hereditary tendency we have then three active influences which aid in the development of rheumatic fever, namely, chilling, excessive muscular exercise and scarlet-fever.
As a rule, an attack of articular rheumatism is gradual in onset has a moderate fever, with tenderness and slight swelling of one or several joints, and with proper treatment and no insertion complications, runs its course in from two to three weeks. But absence of joint involvement is one of the peculiarities of rheumatism in children, and the only indication of an attack may be either an endo- or pericarditis, an acute inflammation of the pharynx, or of the respiratory tract. Attacks of this kind are extremely common in early life, and because of the joints not being involved their rheumatic nature is consequently overlooked.
Attacks of some forms of eczema, of urticaria, of pleurisy, an occasional pneumonia, chorea, and the appearance of tendinous nodules, are manifestations of a rheumatic diathesis, as also some forms of hemicrania and gastralgia. Many cases of intractable eczema are based on a rheumatic diathesis, and when treated from this stand point become curable.
Rheumatism then shows a tendency to a more widespread range of attack upon the tissues of childhood and extends over a longer period of time than in adults. It manifestations are quite different therefore from those in the adult, and have developed the fact that in children arthritis is at its minimum, while endocarditis is at its maximum, showing that in the rheumatism of children involvement of the heart plays a most important part.
From 50 to 80 per cent. Of cases of endocarditis in children, according to Cheadle and others, are traceable to rheumatism. It may and often does appear alone, the sole expression of the attack, and may be sub acute, protracted or relapsing. The mitral valves are the parts most commonly affected, and when the only point of attack, is usually followed by chorea and if progressive is attended by the formation of tendinous nodules. These are found chiefly about the joints, particularly of the elbows and knees, and along the borders of the spine and shoulder blades. Let any of the above-mentioned affections crop out, though over a period of months or even years, especially when accompanied by cardiac trouble, the presumption is rheumatism is at the bottom, and the more of them appear together the more positive the presumption. An erythema or tonsillitis alone might require more evidence. There is also some doubt as to pneumonia appearing as a distinct form of rheumatism; it is undeniable as to pleurisy.
As to the symptoms of a rheumatic heart affection in children, dilatation is one of the earliest, yet there is often very little distress manifested even in very grave cases. Edema and a flushed race and rarely present; sometimes only a little puffiness of the face or about one or the other joint, but an anaemic condition is quite common, and when markedly present and persistent is for boding of evil.
In making a diagnosis of rheumatic fever in children it should be distinguished from infantile paralysis and from pyaemia, when the joints are acutely affected and there is a suppurative tendency; also from the tender swelling of limbs and ankles as found at times in rickets.
Rheumatic children are usually of a highly nervous disposition, easily excited, easily frightened, and do not have the power to rush and fly about so characteristic of an ordinary healthy child; in fact, their spirit is always stronger than their body.
How important then in all cases of diseases of children when any of the above-mentioned ailments appear, especially the ordinary colds, fever, sore throat and growing pains, that they be fully investigated, their true nature and import ascertained, and if found in rheumatic families, be put on our guard at once as the probabilities are of having to deal with a case of rheumatic fever, and make frequent careful examinations of the heart.
Dr. F. J. Poynton, of London, in his last of a series of lectures on this subject, gives the following physical signs of rheumatically dilated heart, as it, is probably one of the earliest symptoms developed namely: First, an increase in frequency and a lowering of the tension of the pulse; second, an outward movement and feebleness of the cardiac impulse; third, an increase of the deep cardiac dullness to the right and left, fourth shortening of the first sound over the impulse, and an accentuation of the second sound at the pulmonary base; fifth, and lastly, in some cases a soft systolic murmur heard most clearly internal to the nipple.
Most watchful care in the diseases of children cannot be too strongly urged owing to the fact of greater liability to endocarditis in early life and consequent permanent damage to the heart tissues. The sequences are even of more importance than the primary attack, since relapses at shorter or longer intervals are common. There is also a great tendency for the inflammation to continue and smolder in a sub acute form after an attack, and ere we are aware of it a chronic state is reached and the mischief is irreparable. Then follows a constant change from bad to worse, progressive anaemia and dyspnoea set in, the pulse becomes more rapid and feeble. And the patient, still in the prime of life gradually sinks away to a premature grave as a result of a neglected, weakened and incompetent heart.