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48
Onset.
Persistence
of symptoms.
Location of
pains.
Time of
onset of
pains.
Meteorological
conditions.
From this analysis, the following facts emerge:—
Onset of the (6) cases (50 cases); in 24 per cent, there is evidence to suggest that the disease
followed an acute infectious illness (scarlatina heading the list). A similar onset is suggested
in 8 per cent, of the insidious cases without carditis ((c) and (d) comprising 260 cases in all). The
conclusion to be drawn from this would seem to be that particular attention must be directed
to children who complain of pains which seem to have followed an acute illness, especially
scarlatina.

The striking facts which emerge from these figures are (i) that, on the whole, the most
serious cases keep as free from symptoms as the presumably milder cases, and (ii) that a great
many children continue to complain persistently of pains over a long period in spite of the fact
that there are no objective signs to account for them. In fact, Table VII is to some extent misleading
in that Group (d) naturally includes a number of very mild cases whose symptoms are
of a transitory nature, and these swell the figures. If these were excluded and segregated to
a class by themselves ("possibly non-rheumatic,") the proportion of persistent complainers
among the "doubtful cases" would appear larger.
Pains which persist in one joint over a long period, suggest that some disease other than
rheumatism must be excluded (e.g., tuberculosis, coxa vara, flat-foot, trauma, etc.). Apart from
this, pains in the joints themselves are more likely to be rheumatic than pains in the muscles,
etc. Definite swelling of a joint (other gross diseases being excluded) must be taken as diagnostic
of "true rheumatism" and a child who has had a swollen joint must undergo a course of serious
treatment. Evidence on the matter of swollen joints, however, seems extraordinarily difficult
to elicit from parents.

* These observations apply to pains suffered during "quiescent" periods; the pains of acute
rheumatic attacks are not described.
Attempts to ascertain the time of day at which pains were most likely to occur in the
different groups, have been disappointing. On the face of it, pains which occur during the night
and keep the child awake would seem to be of some severity, but they appear to have come in
the night as frequently among the cases who otherwise seem of a mild nature as in the more serious
cases.
Complaints of pains being worse in damp weather are less frequent than might be expected,
but this may be partly due to lack of observation on the part of the mothers. In most cases,
children are not seen sufficiently frequently to make careful observations on the relation of
pains to weather; but the impression is certainly gathered that bouts of pain are more likely to
occur as the result of sudden changes, than as the result of any particular type of weather.
Incidentally, conditions which tend to make people sensitive to meteorological changes may
make them subject to rheumatism; and, in this connection, it is tentatively suggested that a
very thin-walled house (the interior of which will tend to be of changeable temperature) may be
less suitable for a rheumatic child than an overcrowded unattractive residence in a tenement
dwelling or old house, which, however, has thick well-built solid walls.
At a rheumatism supervisory centre, one's efforts are very largely directed to the detection
of early signs of carditis and it is in the hope of preventing serious cardiac damage that so many
mild cases of suspected rheumatism are kept under continued observation. One cannot help
being impressed with the large number of children who continue for many years to complain of