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nodules varying in size from that of a lentil to that of a small bean were recorded
in seven cases in this series. These were found mostly on the occiput, the back of
the hands, and on the elbows. Six out of the seven were taken directly from hospital
and all were in cases of the more acute type. This feature when seen appears to
be matter of moment in rheumatism. Swelling of one or other of the joints, usually
ankles, wrists or elbows, was present in 15 cases, and appears mainly at feverish
or definitely febrile periods in the disease.
Tonsillectomy had been performed in 16 children prior to, and in 24 children
subsequent to, the history of onset, and enlarged tonsils were present in 43 children.
The frequent presence or past presence of tonsils, mainly showing signs of chronic
inflammation, is important, since the role played by these in the aetiology of
rheumatism is still uncertain. The tonsils were seldom markedly enlarged, but often
appeared small, and it may be that this small or buried type of tonsil is often missed.
In almost all the cases, even when the tonsils were not enlarged, the pillars of the
fauces were inflamed, the common appearance of the throat resembling that of
a child with a "cold " though catarrhal exudations were seldom seen.
An interesting point in this series was that the enlarged tonsils were seldom
accompanied by adenoidal growths sufficient to be remarked, and the typical adenoidal
facies was not noted in any one of these children. Nor was the presence of
obviously enlarged cervical glands a feature; small palpable glands were certainly
present in many of the thin children, but would appear more an expression of geneial
ill nurture than of specific importance. In this connection it may be noted that
catarrhal signs in any of the mucous membranes or of the lungs were especially
absent. No child had conjunctival infection (two had keratitis of old standing)
and in three only was there a history of bronchitis or recurrent nasal catarrh. One
child had had a radical mastoidectomy and another had otorrhea when examined.
It would appear that it is not the " catarrhal " child that is subject to rheumatism.
Three children out of this series had been admitted to hospital with acute
appendicitis. Two were operated on, one with a gangrenous appendix ; all three
subsequently developed rheumatic fever.
The above classification of pulse rates and temperatures is not sound, since
the ages of these children varied between five and 15 years, and the pulse rate in
younger children is normally quicker than in older children, and their temperatures
vary more. The most that can be said is that in rheumatism pulse rates and
temperatures show wide variations for little apparent cause.
The interpretation of early cardiac involvement in school children was discussed
in the London County Council Annual Report for 1924, page 77 ; for simplicity
the present series was classed under three headings—Nil, suspicious and definitely
affected. There were 19 cases in which nothing abnormal was found, and 42 cases
with suspicious signs. Hearts were looked upon with suspicion when there was slight
dilation, that is, the " left border cardiac dulness " was beyond the nipple line ;
or, when there was a systolic murmur of indefinite origin at the apex ; or, variation
in the tone, rhythm and force of the beats, sufficient to raise doubts as to their
significance; or, any combination of these faults; 39 children had definitely and
permanently affected hearts.
No mention is made in the above table of the temperamental make up of these
children, and it is scarcely necessary—the generally malnourished conditions of these
children, coupled with the clear evidence of endocrine—sympathetic imbalance
as shown by their circulatory inefficiency, which go hand in hand with the unstable
type of child whose higher mental and affective attributes show just such inequalities
as do the maladjusted physiological functions of the body—clearly shows that
rheumatism either establishes or aggravates an already existing instability in children.
In Dr. Dobbie's opinion it is the child of nervous type that provides the soil in which
the seeds of rheumatism take root.