ing away at 120 to 160 per minute; there is acute pericarditis and mitral disease also, though this is often uncertain from the confusion of sound produced by the pericarditis and the rapid action. The chest shows considerable dulness and high-pitched tubular breathing, probably from the seventh or eighth rib downwards, at both bases. In such cases it is very difficult to say what drugs do good, and whether a case is to do well or badly. Undoubtedly the most essential requisites are careful nursing and judicious feeding; these, and opium given internally, will steer many cases through the pericarditis-the heart's action quieting down, and the pleuritic effusion and solidification of the lung slowly clearing off. But there are, unfortunately, many cases, not differing much in the physical conditions ascertainable, in which the child becomes more restless, vomiting supervenes (one of the worst symptoms possible in cases of this kind), and the child dies quite quickly. These are cases in which brandy must be administered freely. Ether is, no doubt, a useful drug under these circumstances, but it is not one that children take readily, and it is often vomited, in which case, however, it may be injected subcutaneously.

Regarding the treatment of the rheumatic child-whether it be rheumatic by any attack of former acute rheumatism, or its tendencies shown by some of the lesser ailments included in rheumatism and associated with hereditary taintthere is much to be said. Such children require the most watchful medical care, and much more than is usually considered necessary by their parents-uninstructed, as most of them are, as to the meaning of trivial ailments in such children. A tonsillitis, a headache, paleness, etc., do not necessarily suggest the advisability of an examination of the heart; but such conditions in these children are to be looked upon as part of the life-history of rheumatism, and unless the heart be examined-shall I say, supervised (as

indicating the necessity for prolonged watchfulness)-disease may be creeping on where we least expect it. These are some of the cases where the doctor should be remunerated for keeping the child well, rather than called in to cure it when actually ill. His fee should be an annual retainer, irrespective of any illness, and there is no doubt that rheumatism and its results would be diminished. The management of the rheumatic child requires discretion at all points. It is not only that its diet and its clothing require it, education and play alike call for advice in many instances, and the question of residence, although often quite beyond power of alteration, is one of vital importance. Of course, until we know what rheumatism is, we must deal to some extent in generalities, which may be very open to discussion; but with this admission, it may be said that warm flannel clothing is essential; the diet should be varied, and contain plenty of easily digested vegetables, in addition to the milk and ordinary food; and both as regards work and play, the slightest indications of excess, in the way of exhaustion— whether this be temporary or continuous, any headache, tendency to nightmare, or what has been called nervousness -must lead to immediate moderation. For such children the greatest care should be exercised in the selection of a school, both as to a dry, warm climate, the home life therein, and the happiness of the child; and unless all these things are satisfactory, it is far safer to keep the child at home.

The rheumatic child is one who requires drugs on occasion. Whenever it is below par, or getting anæmic, some good tonic should be administered, such as Easton's syrup, with which I am in the habit of combining arsenic as one of the most useful of remedies for cases of this sort. Five drops of Fowler's solution, or seven, or ten, with half a teaspoonful of Easton's syrup, taken continuously for a month

or six weeks, is a most valuable help in these cases, and cod-liver oil, stout, maltine, and such things, are also to be recommended.

For the nervous or excitable condition, particularly in girls, the bromide of ammonium, bromide of potassium, hydrobromic acid, and manganese are of value; and for the nightmare which occurs in younger children, bromide of potassium and hydrate of chloral combined, form almost a specific. Five grains of the bromide and five of chloral (half-drachm of the syrup), may be given to a child two years old, and continued as a draught at bedtime for a few days, with the almost certainty of success, care being at the same time exercised that the excitement of the day be reduced to its minimum. Of the abdominal pains I have already spoken, and advised the administration of Dover's powder. Such children require attention to the bowels, which are liable to be irregular. If so, some gentle aperient in the shape of fluid magnesia, effervescing citrate, liquorice powder, syrup of senna, confection of senna, or the fluid extract of cascara sagrada, in doses of ten to thirty minims, may be given, and a little tincture of nux vomica also is sometimes of advantage. The treatment of nocturnal incontinence is discussed in "Genito-urinary Diseases," page 452.

CHAPTER XLIV.

HEART DISEASE.

IN studying diseases of the heart in children, it is necessary to be aware of a few preliminaries. The heart's action is more rapid than in adults. It is not necessary to burden the memory with the precise data for particular periods, but it will suffice to remember that at birth it is about a hundred per minute, for the first two years it quickens up to one hundred and fifteen or one hundred and twenty, and that subsequently it gradually slows again. From two to six it remains about a hundred, and then gradually drops to seventy or eighty. In early childhood there is a good deal of difference—often as much as twenty beats per minutebetween sleeping and waking; the heart, of course, beating slow in sleep. This is naturally a matter of great importance in disease, for if the heart's action can be thus reduced, as much sleep as possible will certainly be advisable in cases in which the heart is diseased, and needs all the rest that can be obtained for it. This difference is said only to apply to young children. One cannot, however, dogmatize on this matter, for it would appear, from some observations made for me by Dr. Newnham at the Evelina Hospital, that the amount of slowing is subject to some variability. several cases it was noticed to be three or four beats quicker during sleep; although on the whole there was a wellmarked reduction of four or six beats, and sometimes as much as thirty beats per minute; and this not confined by any means to the youngest children, but to those of seven, eight, and nine years. The heart's action is also less regu

In

lar in its rhythm-one beat will be feeble, the next strong, and so on. The point of this is chiefly, as Meigs and Pepper remark, that caution must be exercised in drawing conclusions in cases of doubtful meningitis, in which disease an irregular pulse is one of the most valuable diagnostic indications. The heart's action is often more diffused upon the surface and visible than in adults; the position and the impulse with regard to the nipple is more variable, and the impulse is often higher than normal in the fourth interspace. The præcordial dulness is a little larger. Perhaps this would not be so in children of absolutely healthy standard; but so many suffer from moderate chest distortions, from bygone collapse of the lung and chest wall, that the lung which should cover the heart more thoroughly is less expanded than natural. The heart sounds are usually more tic-tac—that is, less sustained, than in adults; although, given an adequate cause-acute Bright's disease, for example-they will become thick and laboring as in an adult. This is well worth notice, for I have often had my attention called to the existence of albuminuria by the peculiar lengthening and laboring quality of the first sound. This is perhaps the more striking when one has to confess-at least, I should do so that any corresponding changes in the pulse can but seldom be shown to exist. It is very difficult, indeed, to gain reliable information as regards volume and force, and with the sphygmograph I have met with little but disappointment in children.

There is not much that is peculiar to childhood in diseases of the heart, excepting, of course, the various forms of congenital disease; but there are one or two points which are worth remark, and even where the diseases follow the same lines as those of adults, the obscurity of origin of many cases in grown-up people makes the various forms of heart disease in early life of considerable etiological value.