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Clinical Report.
One more session was held during the past year than in 1937, and the average attendance increased from
26-1 to 27-72. There are no statistics in the country to prove whether the incidence of rheumatism in children
is diminishing or not; rheumatism is not universally notifiable, and the notifications in the Royal Borough
of Kensington do not suggest that the number of children suffering from this disease is diminishing. It is true
there were larger figures in the first three years. These, however, are due to notification of children with permanent
cardiac abnormalities who developed the disease before the period of notification. The question naturally arises,
therefore, whether the services provided by public authorities during the last decade have been of benefit to
the community. We are quite sure that they have because, although an equal number of cases may occur, there
is not a shadow of doubt that the cardiac complications of this disease are far less extensive and severe. Apart
from the damage to the heart's endocardium, myocardium and pericardium, juvenile rheumatism does not as a
rule leave any permanent disability, the acute arthritis which often occurs clearing up completely.
Before this last decade one saw numbers of children suffering from a pancarditis of great severity. This
resulted in such extensive damage to the whole heart that they did not recover or reach adult life; in others,
the damage was less severe, but sufficient to limit permanently the activities of these patients. Thus they were
not able to undertake anything but light work and in females childbirth was a danger to life. In chorea also,
the condition was often so severe that the children could not possibly feed themselves, for weeks they had to be
screened from other children, and their nursing was a difficult problem.
Now we rarely see a severe case either of carditis or chorea. The progress of the acute cases is closely watched
as one of the doctors at the centre is on the honorary staff of the Princess Louise Kensington Hospital for Children,
to which a large proportion of the acute cases are admitted. Further, the social workers report progress in cases
which are nursed at home or admitted to other hospitals. The cases of chorea, although their symptoms may
have persisted for some time when they were in their own homes, usually disappear within the first week or two
after admission to hospital.
The accompanying table will show that during the period under review eight cases of chorea were admitted
to Princess Louise Kensington hospital, where their progress was closely observed. None of them was severe.
At the moment of writing there is a fairly acute case in the wards, admitted from the clinic. For a day or two
she could hardly feed herself, but after three weeks of in-patient treatment her symptoms have almost subsided.
A rather drastic hyperpyrexial treatment has been suggested for persistently severe cases, but during the last
three years every case admitted has so quickly responded to the usual routine treatment of rest and sedatives
that one has not been justified in submitting the child to hyperpyrexial treatment.
During the year thirteen cases of active juvenile rheumatism were admitted, and were all very mild except
two. One child had a fairly extensive cardiac lesion; her attack this year was an exacerbation of old-standing
heart disease, she has responded well and her future activities should not be severely limited. The other was
admitted as an acute rheumatic carditis; she developed infective endocarditis and died quite shortly after
admission. When first seen early in 1938, she had a well developed mitral stenosis; although she had no history
of an acute attack of juvenile rheumatism, she had suffered from pains in her calves and legs on and off for two
years. Another three cases are known to have died during this year. One of these was in a cardiac home; she
had been admitted to Princess Louise hospital during the previous year. The second had had an acute attack
of rheumatism in 1932, preceded by rheumatic pains. She gradually developed mitral stenosis, but remained
well until 1937 when she developed nephritis, and it is thought that this was the cause of her death. The third
had his first attack in 1932, a second one in 1933, and a third in 1937; he died at home. There was no postmortem,
but from the history of the case it is possible that this also was a case of infective endocarditis in addition
to rheumatic infection. Before admission some of these children had been resting at home under observation
with no improvement.