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(a) Thirteen cases.—These had arthritis and fever or chorea, but no murmur or other abnormality of the
heart was demonstrated during the five or more years under observation.
(b) Seven cases.—These had arthritis and fever or chorea, and during the period of observation they developed
various types of slight abnormalities of the heart, variable and not at any time thought to indicate cardiac
damage.
(c) One case.—Similar to those in group (b), but the basal murmur did not vary during the five years.
(d) Fourteen cases.—In all these cases there had been at one time or another evidence of definite cardiac
involvement—enlargement of the heart, apical systolic murmurs, or pericardial rub. When last examined,
however, these signs had disappeared, and no evidence of any cardiac abnormality could be detected,
(d) Eight cases.—In these there was evidence of heart disease when first seen, and this remained stationary,
showing no further cardiac damage, although during the five years of observation two had an attack of chorea
and three had a second attack of acute rheumatism. Five of these cases have mitral incompetence, and three
mitral stenosis.
(f) Six cases (two of these cases are also included in group (d)).—These are of interest, as they had a cardiac
lesion, but had no symptoms suggesting juvenile rheumatism.
(g) Twelve cases.—These cases, although notifiable, had no evidence of carditis when first seen, but they
developed lesions at a later date. When last seen five had mitral regurgitation, five had mitral stenosis, and
two had a double lesion—mitral stenosis and aortic incompetence. Of these twelve cases, two when first seen
were beginning an attack of acute juvenile rheumatism. Four developed lesions without any evidence of an
acute attack, and six had further attacks of chorea or acute rheumatism.
(h) Twelve cases.—These cases had definite evidence of. cardiac involvement when first seen and during the
period of observation the heart was further damaged. Five had no intermediate acute attack, but the signs
of mitral incompetence changed to those of mitral stenosis, and seven had acute exacerbations, five developing
aortic regurgitations as well as mitral stenosis.
Summary.
(1) Twenty-six cases (25 per cent.) have not become notifiable during the five years or more that they have been
under supervision. Twenty-one of these cases, although they had no definite arthritis or fever and were not
notifiable, had rheumatic pains at times during the period under observation and were therefore potential cases
of juvenile rheumatism. That 21 or 20 per cent., who were unnotifiable and had rheumatic pains on and off during
the five or more years, did not develop an acute attack, may be largely due to the care that had been taken.
These supervised children, if the pains are definite and their general health is not altogether satisfactory,
are frequently sent to bed for a week or more at home ; the district nurse attends night and morning to take
pulse and temperature, and appropriate treatment is advised. The social worker attends, wherever possible, to
see that the instructions are carried out. With this arrangement it has been found, on many occasions, that
the pains subside and the general health improves. It is justifiable to conclude that a certain number of acute
attacks have been prevented by this method, especially as in some of the cases the pains had been present for
some weeks before the child was brought to the centre, and the symptoms had shown no tendency to improve
until this treatment was adopted. Also the fact that the parents, usually the mother, but occasionally the father,
grandparent or other relative have been trained to bring these children to the centre and keep them under
regular supervision for five years in the absence of any acute illness, is significant evidence of the educational
value of the centre. There is no doubt that the centre and the public medical service have trained the parents
to realise the possible seriousness of the " growing pains " which used to be considered so lightly. Such
educational work is not the least important part of the centre's responsibility.
(2) Only seven cases which were not notifiable when first seen have developed cardiac lesions.
(3) Of the nineteen patients with chorea, only ten have a cardiac lesion. We have noticed that an
increasing number of children are sent up to the centre by schoolmasters and schoolmistresses who have observed
suspicious movements of face and limbs and told the parents to obtain advice. Sometimes a diagnosis of chorea
is made, and sometimes the movements are only nervous habits ; the latter type of case can be referred, if
necessary, to the child guidance clinic. Children with even mild chorea and no evidence of carditis are usually
sent for institutional treatment as they do not progress well in the home. In hospital their symptoms quickly
subside, but it has been found that they must not be allowed to return to their ordinary activities too soon or
the movements will recur. Convalescent treatment is therefore advised, although the parents will sometimes
refuse to permit this owing to the expense involved.
(4) Twenty-one cases (20 per cent. of the whole) developed mitral stenosis or aortic regurgitation, or both :
of these only eleven (50 per cent.) had an acute arthritic attack. Four had chorea, and six had neither chorea
nor acute arthritic attack; three of these, however, had been in-patients in hospital for sub-acute rheumatism
or carditis more than two years before the mitral stenosis was noted, so that it is probable that the real onset of
the cardiac lesion was at that time.
(5) Six cases with cardiac lesions had no rheumatic symptoms, that is to say that they had no reported
rheumatic pains or arthritis. It may be that the pains occurred at an early age when the child could not easily
explain or remember his symptoms, and the parent was not observant, but in these cases no such historv could
be obtained.
(6) Thirty-five notifiable cases (33 per cent.) had no organic lesion when last seen. Of these, fourteen cases
originally had a definite cardiac lesion and have apparently recovered completely.
It must be noted that at the end of the period of observation sixty-one, or 58 per cent., of the cases have no
demonstrable cardiac lesion. Twenty-six of these were potential rheumatics, nine had had chorea, twenty-six
had had rheumatic fever, and no less than fourteen had haa clinical evidence of cardiac damage at some stage
of their illness. Permanent cardiac damage is, of course, the consequence most to be feared in cases of juvenile
rheumatism, owing to the serious invalidism it may entail, with premature death. This high rate of freedom
from cardiac damage may be ascribed in part to the preventive measures already described, in part to early
diagnosis at the centre, and consequent hospitilisation or care in the home of all cases of definite juvenile
rheumatism, and in part possibly to the arrangements made at the centre for convalescent treatment for
debilitated children. On the whole, therefore, the analysis of these cases would seem to be very satisfactory
and an indication of the prophylactic value of the supervisory centre.