Rheumatic Fever.—The main features of rheumatic fever are the same at all ages. Fever, pain in the limbs, swelling of the joints, sweats unattended by that relief which usually accompanies abundant action of the skin in fevers, are its characteristics. In the child all these symptoms are usually less even than in the adult. The swelling of the joints in particular is less considerable, and both the pain and the swelling are apt to wander from one to another joint, or to a different limb, instead of remaining fixed as they do in the grown person for several days in the same joint, even though fresh joints may be implicated in the course of the disease.
These circumstances tend to make people look on rheumatic fever in the child too often as a comparatively trivial ailment; and this not only because the suffering which attends the disease is slighter, but because its duration is also shorter. But there is one fact which forbids this low estimate of its importance, and that is the great tendency to affection of the heart even in cases of comparatively mild rheumatism in the child; while in the grown person there is a direct relation between the general severity of the rheumatic symptoms and the liability of the heart to be involved. I have already stated that nine out of ten of all cases of heart disease in early life, not due to original malformation, are of rheumatic origin, and further that heart disease comes on in the course of four out of five cases of rheumatic fever in the child, slight as well as severe. It seldom occurs before the third or fourth day of the illness, so that if parents take the alarm at the very outset, it is usually though not invariably possible for the doctor by judicious treatment to anticipate and to prevent its occurrence, or at any rate greatly to control its progress.
Every threatening of rheumatism, therefore, is to be watched with the most anxious care, since so serious a complication as disease of the heart may accompany extremely slight general symptoms. It is wise too, to place any child in whom general feverish symptoms come on at once under medical observation, for though it does not usually happen, yet it does sometimes occur, that rheumatic inflammation attacks the heart before any other local signs of the malady have manifested themselves. It is scarcely necessary to add that tenfold precautions are needed when rheumatism has once occurred, since the liability to its return is very great, and the heart which escaped in the first attack may suffer in the second; or the comparatively small mischief done the first time may become an incurable disorder.
Ague.—Intermittent fever or ague is very rare in childhood in London; or at any rate it is very rare among children of the wealthier classes. I believe it is everywhere rarer among children than among grown persons, probably because they are as a rule less exposed to those malarious influences which produce it. In the child it generally takes the form of tertian ague, that is to say the attack recurs every second day; one day of freedom intervening between two attacks.
The three stages of shivering, heat, and sweating are less marked in the child than in the grown person, and this indistinctness of its symptoms is greater in proportion to the tenderer age of the child. Shivering is scarcely ever well-marked, a condition of unaccountable depression usually taking its place, while once or twice I have known convulsions occur which gave rise to the apprehension that disease of the brain existed. The hot stage is long, and passes off gradually without the profuse perspiration that occurs in the grown person, and the child even between the attacks is almost always more or less ailing.
A first and even a second attack may puzzle not the parents only, but also the doctor; but after the symptoms have returned a few times, the child being neither better nor worse in the intervals, it becomes evident that no serious disease is impending. The risk of an overhasty conclusion is that the depression and disturbance of the nervous system may be supposed to imply the existence of brain disease; and lead to unsuitable treatment, instead of the administration of quinine, which nine times out of ten proves a specific for ague. The rapid increase of temperature in the attack, and its equally rapid subsidence afterwards, will, if carefully noted, preserve from error.
There is much that is obscure with reference to the nature both of rheumatic and intermittent fever. They differ from other fevers not only by being neither contagious nor infectious but also by their readiness to return, while a single attack of any of the others furnishes a guarantee, and often a complete guarantee, against its recurrence. In addition to these peculiarities, the fevers of which I have now to speak are characterised by running a certain definite course, being accompanied by certain peculiar appearances on the surface (generally rashes on the skin, whence their name of eruptive fevers); being attended each with its own peculiar dangers, and all having a tendency to what is termed epidemic prevalence; that is to say to occur one year, and without obvious cause with vastly greater frequency than in other years.
Mumps.—It has been questioned whether that painful but not dangerous ailment the mumps, ought or ought not to be classed with these fevers. I think it should, for it is contagious, infectious, runs a fairly definite course, is attended with invariable external appearances, often prevails epidemically, and one attack preserves in most instances from a second.
It very seldom befalls children under seven years of age, and is more frequent in early youth than in childhood. It sets in with the ordinary symptoms of a cold, which are followed in about twenty-four hours by stiffness of the neck, and pain about the lower jaw, which is increased by speaking or swallowing. At the same time a swelling appears, sometimes on one side sometimes on both of the lower jaw, and increases very rapidly so as to occasion great disfigurement of the face. The swelling goes on to increase, and to become more tense, attended with more head-ache, fever, and discomfort for some forty-eight hours, but then it begins to lessen, and the general illness subsides rapidly, though the enlarged gland, for that is the cause of the swelling, sometimes does not return to its natural size for a week, ten days, or more; and now and then, though very rarely, an abscess forms, which is both tedious and troublesome.
The treatment suitable for a severe common cold, together with the constant application of a warm poultice to the swollen gland, is all that is usually required, though the doctor's help is often needed to relieve the suffering which for the first day or two in many instances attends the ailment.