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91
"Many children not definitely rheumatic but having something in common
with rheumatic symptoms were seen ; perhaps the most numerous class was that
with so-called debility, thin, under-nourished and pale, with flabby, undeveloped
muscles of poor tone with sagging posture and lacking in energy. Such children
benefit greatly by convalescent treatment, and some do well at day or residential
open-air schools. Another smaller class, usually of better social standing, gives a
history of cyclical vomiting or recurrent bilious attacks followed by a day or two of
malaise, of tiredness, and, may be, of vague pains and discomfort in the limbs not
thought to be due to rheumatism ; wholesome dietetic advice is indicated in these
cases. Some children, of unstable type, were seen who have occasional mild pyrexial
attacks with tachycardia without developing rheumatism or other recognisable
disease.
" Pain is the one complaint common to most of these, and to rheumatism,
and while no hard and fast rule can be laid down, infrequent transient and vague
pains in the large muscles and over the long bones are not so indicative of rheumatism
as are the more insistent and frequent pains related to the larger joints. When such
pains are associated with swelling which moves from one to another of the larger
joints, rheumatism is present, but even in the absence of arthritis, of rheumatic
fever, or of chorea, the history and clinical appearance outlined in the Annual Report
for 1927 is commonly found in the child suSering from early rheumatism.
" Seventy-three Elizabeth Bullock and 80 Downham children were thought not
to be rheumatic and 25 at the Elizabeth Bullock centre and 30 at Downham were
discharged after their first visit. The others were referred for re-examination at
varying intervals, and of these, 19 Elizabeth Bullock and 17 Downham children
were recommended for convalescent or residential open-air school.
" The value of tonsillectomy as a protective or an ameliorative step in rheumatism
would be apparent were it agreed that there is a higher incidence of inflamed tonsils
in rheumatic children. The normal amount of lymphoid tissue in the infant up to
five years of age is not known, but somewhere about this age, when the throat is
healthy, tonsils or lymphoid tissue gradually disappear ; their physiological function
appears to have terminated. Where there is marked hypertrophy or obvious local
sepsis giving rise to symptoms, no one hesitates to remove tonsils and adenoids,
and almost always with benefit to the child. In all investigations by the Council's
officers, with any bearing on the tonsils, the findings subsequent to tonsillectomy
have been such as to cause Dr. C. J. Thomas to remark, ' It is better to have had
tonsils and lost them than never to have had tonsils at all.' The explanation is
no doubt partly due to greater parental care shown by submitting the child to operation,
especially as these enquiries have been in poorer elementary schools where the
social conditions are at their worst and defects are more frequent. But the explanation
may also be that when nature has done with the tonsils, their presence has become
a danger in children whose throats are chronically inflamed and in these removal
does good.
" The combination of tonsillitis and of sore throats with rheumatism is universally
admitted. In contradistinction to the catarrhal child, the proliferative changes
in rheumatism appear specially to affect connective rather than lymphoid or mucoid
tissues and in these, even when sepsis is present in the throat, we find neither much
increase in the size of the tonsils nor marked adenoids. The tonsils though small are
usually inflamed and the surfaces irregular, whilst the edges of the pillars are injected,
the tonsillar glands are not markedly enlarged as though they were no longer a
barrier to infection, for the rheumatic child shows some degree of toxaemia. It also
appears to be a fact that incomplete tonsillectomy, possibly by exposing a relatively
unprotected surface to infection, increases the tendency to severe toxaemia and grave
carditis, thus indicating that infection in the tonsils or through the tonsils has a
definite bearing on the disease.