smelling pus were removed, and the child improved for a short time, when symptoms indicative of the reformation of purulent matter demanded better drainage, which was secured by an incision and the introduction of a tube.

The liver and spleen were enlarged. A diarrhoea set in, which was totally uncontrollable, to which the child succumbed six weeks after we first saw her.

Post-mortem.-Examination was made a few hours after death, and as we report the case solely for the condition of the pericardium, suffice it to say that the left pleural cavity contained several ounces of pus, and presented the usual appearances in such cases.

Heart and pericardium.-The former much enlarged, and the latter adherent to the adjacent structures. The parietal pericardium was much thickened and covered by a pyogenic membrane; the visceral layer was thickened and covered by pus; the layers were adherent over left ventricle.

The following case, recorded by Broxholm,* is of extreme interest on account of the fact that the child complained of no pain, and, although effusion was present in marked degree, did not present either dyspnoea or orthopnoea. The child, a boy aged five, expired suddenly before medical aid could reach him. He had, however enjoyed seemingly good health. Sectio cadaveris twenty-four hours after death.

Child was rickety.

Meninges were vascular and congested, no effusion; brain was very vascular. No ventricular effusion, none at base of brain. The lungs were adherent by lymph-deposits, some old, some recent. Tubercles infiltrated throughout lungs.

Pericardium.-Much distended, contained one pint of straw-colored effusion, with numerous flakes of greenish-colored lymph the interior of pericardium, all over its surface, presented deposits of fibro-plastic matter, rendering its surface exceedingly rough and granular. Heart-muscle hypertrophied, and presented over the centre of the ventricles tw patches of a light-brown color, feeling very firm and hard, thinner than the surrounding tissue, and cutting like cartilage.

* Lancet, London, vol. i., 1856, p. 343.

One segment of the mitral valve was calcified, and in the chordæ tendinæ attached to the same segment, a little removed from their point of attachment, were also noted calcareous degenerations. The tricuspid valve was much thickened, having fibrinous deposits on its edges.

Cavities all dilated and filled with coagulated blood. The stomach, liver, spleen, and other organs appeared healthy, but the mesentric glands were enlarged.

The child had never had rheumatism, as far as could be determined by the history and the post-mortem appearance.

Kirby's case, before referred to, well illustrates the disease as intercurrent in the eruptive fevers. A previously healthy boy, aged one year and eleven months, had been ill for five or six days with varicella; child developed cough, high temperature, and oedema of leg; sank lower and lower, lying on his back in his mother's lap, countenance pale, pupils dilated, and surface cold, pulseless at wrist; respiration labored; over præcordial region increased dulness; normal sounds of heart scarcely audible, but a friction-sound, although faint, was dis tinctly heard; child died.

Post-mortem.—Pericardium very vascular and much distended by fluid; the sac was nearly full of yellow flaky serum, and its serous lining, throughout its whole extent, was coated with rough villous-looking lymph. In the pleura, also on both sides of the thorax, where it covers the upper portion of the diaphragm, there were patches of coagulable lymph.

To illustrate the pyæmic form of pericarditis we will select the case recorded by W. S. Kirkes.† A boy, aged sixteen, referred to on page 206 of this article, was admitted to St. Bartholomew's Hospital, having received a violent kick on the shin, about an inch below the knee. Four days after receipt of injury the boy applied for admittance to hospital; there was then a red tense swelling over the injured part, the child presenting a peculiar haggard, anxious look. Auscultation revealed a well-marked pericardial friction-sound; the patient complained of general pains in the limbs, and of feeling very

* Lancet, London, 1860, vol. i. p. 87.

+ London Med. Times and Gaz., Nov. 1, 1862, p. 461.

ill. There was, however, no swelling, redness, or particular tenderness of any joint; no symptoms of rheumatism whatever. The skin was hot, the pulse about 120, and the tongue coated with a yellowish fur. On the day after admission a few small pustules were detected on the front of the chest and abdomen. The swelling over the left shin was incised, and much puriform matter evacuated, and the patient was supported with bark, wine, and good nourishment. The nervous agitation increased, the symptoms became more typhoid, signs of copious pericardial effusion ensued, and the boy died exhausted three days after admission, seven days from the receipt of the injury.

On post-mortem examination the pericardial cavity was distended with turbid serum, while flakes and curdy masses of recent lymph were spread over the surface of the membrane, which was intensely vascular. The muscular tissue of heart was softened, especially about the left ventricle; several diffluent, purulent-looking masses, varying in size from pins' heads to split peas, were scattered through the myocardium, especially at base and in left ventricle. All valves of heart were healthy.

Lungs showed numerous pyæmic deposits. The tibia was much affected and infiltrated with purulent matter.

CHAPTER IV.

THE TREATMENT OF ENDO- AND PERICARDITIS.

As primary endocarditis is of extreme rarity, the treatment of endocardial inflammation is mainly that of the disease with which it is intercurrent. As we have already noted, it is prone to occur as an accompaniment of rheumatism, scarlatina, nephritis, measles, variola, varioloid, erysipelas, diphtheria, and typhoid fever; it has arisen during the course of coxalgia, or in those subject to the diatheses; its association with chorea and erythema nodosum has also already been noted. In the first-mentioned affection endocarditis may appear

early in the case and be the sole manifestation of the rheumatic disease; or, on the other hand, it may be the first local manifestation of a general rheumatic outbreak that in a few days will involve the joints. Cases of endocarditis should be placed at perfect rest: all excitement of any kind whatever is contraindicated. There should be but little bright light admitted to the child's room, nor should conversation be indulged in about the little patient's bedside. Cool acidulated drinks will be gratifying to the patient and will assist in reducing temperature, as lemonade sweetened with glycerin, or neutral mixture. Locally, the præcordia may be irritated by iodine in the following combination :

This mixture will not cause pain by its application and will not be so likely to strip off the epidermis early in the case. The application of tr. iodine alone to the delicate skin of a child will cause undue irritation and make the child very restless, thus exciting cardiac action.

In older children a blister may be applied as large as the præcordial surface. To this raw surface Bouillard has applied daily forty to sixty centigrammes of powdered leaves of digitalis, the irritant action of which maintained the vesicant action. We would, however, sound a word of caution in this method of administering digitalis, as we have noted alarming symptoms from the absorption of digitalis by the skin.

In the rheumatic cases much benefit may be derived from salicylic acid, given as the salicylate of soda, lithia, or quinine. Some authorities administer large doses of nitrate of potash or tartrate of soda and the sulphate of quinine.

The salicylates may be pushed if they appear to act favorably upon the rheumatism and if the cardiac action is not extremely irregular, agitated, or intermittent, and if the pulse is regular and not too frequent.

Digitalis may be exhibited as the tincture in six to eightdrop doses three times a day for a child of five years, the dose being gradually and cautiously increased as needed or decreased

if necessary, as when its effect has once been secured we can maintain the impression with much smaller doses. It must be borne in mind that digitalis is not one of the quickly acting cardiac stimulants, an opinion that our intimate association with students and young practitioners has taught us is very prevalent. In many cases we much prefer the infusion of digitalis flavored with cardamom, in drachm doses.

We have never derived any appreciable benefit from convallaria in any way whatever, and, indeed, it seems to us that the drug merits no place in our consideration.

Veratrum and aconite are to be administered only with the extremest care, and are then to be carefully and intelligently watched. Opium, if given at all, must be in small doses, and is also to be watched most carefully, especially should there be any tendency to cyanosis. Bromide of potassium has been of service in our hands in quieting the patient and allowing the heart an opportunity of establishing its equilibrium. If the cardiac muscle is weakened, possibly the sodium salt would be the better drug. We consider that under no circumstances would it be justifiable to administer chloral.

Upon the whole, the most benefit will probably be derived by an early supersaturation of the blood by the alkalies. The ordinary fever mixture of spts. ætheris nit. and liq. ammoniæ acetatis is alkaline and sedative.

During convalescence great care is to be exercised, as in all probability permanent injury to the valves has been the result of the acute process. A well-selected dietary is to be advised, -one that will be nutritious, but will not demand undue exertion of the gastro-intestinal tract or the large abdominal glands in its assimilation, and above all else will not cause flatulent distention of the stomach and reflexly irritate the heart. This subject has been fully elaborated by one of us in a recent publication.*

The importance of guarding against the evil effects of high temperature merits our serious consideration. The diseases during the course of which endo- and pericardial inflammations are usually associated are apt to have exceedingly high temper

* "Maternity, Infancy, and Childhood." J. B. Lippincott Company.