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The intelligence and educational attainments of 21 convalescent rheumatic
girls at High Wood were enquired into, and it was found that 16 were of normal
intelligence but only one of them was educationally equal to her years, the others
being retarded from one to three years. Three were of subnormal intelligence, and
were three to four years behind with their education. Two were supernormal and
educationally were equal to or better than their years. The intelligence of this
group was roughly what we might expect from a random sample of normal children,
but their educational attainments were distinctly inferior, and this inferiority was
not wholly attributable to lack of schooling, but in large part due to the well known
inferior educability of the unstable child. The picture of the unstable child outlined
above is known to every clinician, and the gradation from this unstable state to
that of frankly declared rheumatism is so insidious that the point when the one ends
and the other begins is at present beyond the knowledge of the physician.
In the absence of cardiac involvement, even with the clinical picture of the
child clear before us, the diagnosis of rheumatism must largely rest on the history
of the case, with, perhaps, other factors to be mentioned later.

In the 18 cases where no history was obtained of pains, six had had rheumatic
fever, nine had had chorea, one had had rheumatic fever and chorea, and two were
diagnosed on the condition of the heart with no previous history; but in all these
cases, except the last two, many of the other symptoms were recorded, e.g., " easily
tired," repeated sore throats, headaches, feverish attacks, etc. The pains complained
of varied in intensity from mere discomfort to acute agony in which the child screamed
if touched. The majority of the parents agreed that there is more complaint of this
symptom during wet and cold weather, and it is usually while these pains are present
that the child feels lax and tired, with little inclination to go out or to do anything
but mope about. The pains may come on every few days, but usually a period of
a month or longer is interspersed, in some cases a year or longer has passed between
these minor symptoms appearing.
Sore throats may or may not coincide with these pains, but they most often do.
Night sweats usually do, though many parents volunteered the information that
the child has always perspired at night. Rheumatic fever and chorea are usually
exhibited at longer intervals, and a point of interest not yet elucidated was that
rheumatic fever appeared to be more prevalent in those children coming from the
better homes. Fidgetiness and twitchings, not so pronounced as to be diagnosed
chorea, is a common symptom or sign in the course of the subacute illness. That the
incidence of rheumatism is heaviest in nervous children is indicated by the fact that
44 parents stated their children had been " nervous " all their lives. Night terrors,
sleep walking and talking are reported in 11 children. Three had had enuresis, two
were stammerers, and two were said to have squinted during minor attacks, and in
another child a squint was the first sign of oncoming chorea.
It may be of interest to note that three other children, not in this series, had
been recommended for treatment as cases of chorea, and were found on examination
to be mental defectives. The erratic movements had been present from birth, and
were thought to be more the expression of a congenital lack of neuro-muscular coordination
than the acquired manifestation of chorea. The presence of tics, oftrepeated
seemingly purposeless movements of a particular group of muscles, is not
uncommonly found in rheumatic children, and it would be interesting to know in
what proportion of children with such tics is rheumatism actually present.