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seen and followed up so more types of symptom or sign can be said to be not
rheumatic. This leaves a smaller group of probable-rheumatics for treatment by
rest and careful supervision; treatment which aims at making heart disease, if it
comes, less crippling, or perhaps preventing heart disease in cases where it would
otherwise have developed.
Some of the patients suffer from disease obviously not rheumatic though the
picture may at first sight have resembled that of sub-acute rheumatism. For
instance, cases have been seen of lymphatic leukaemia, osteo-myelitis, traumatic
myositis ossificans, fracture of the tip of a maleolus, ossifying hsematoma around
an ankle joint, flat foot, cervical rib, psoas abscess, tonsillar sepsis, pyelitis, cystitis,
muscular weakness after illness. Others are sent for heart conditions which can
be distinguished on close examination from those associated with rheumatic heart
disease, as illustrations of which may be given:—congenital heart disease, systolic
murmurs at the base and at the apex which can be ignored, irregularities originating
in the sinus and not indicative of disease, premature contractions of unknown cause
but not rheumatic, attacks of paroxysmal tachycardia, tachycardia or temporary
dilatation or pain in the heart region due to pathological anxiousness.
The majority of the difficult cases is formed of those of possibly rheumatic
children suffering from debility, fainting attacks, tiredness, and pains without joint
swellings, and also of children with fidgetiness which cannot be immediately distinguished
from chorea. As a result of the experience gained elsewhere, and now
especially from the clinic with its organization for following up doubtful diagnoses,
it has become more often possible to be dogmatic and to say in regard to a case
of this nature that a particular case is not rheumatic or choreic, and is no more
liable to rheumatic heart disease than is a normal child.
These children are usually anxious children or over-excitable children, the
majority of them with other and obvious symptoms of psychological disorder, such
as recurring night terrors, frank anxiousness by day, increased urgency and frequency
of micturition apart from urinary tract infection, and so on, and the same wide
group appears in all attempts to classify patients with debility. The same group
formed the bulk of the " pre-tuberculosis child " of a few years ago.
It would, of course, be easy to call all these children " pre-rheumatic," and to
treat them as such. Undoubtedly many of those improperly labelled " pre-tuberculous
" children were very properly treated when they were sent away to sanatoria
and given a good time in the open air. But, apart from the inaccuracy of such a
procedure, the treatment of rheumatism involves long periods of rest and restraint,
and this is the worst treatment for a highly-strung child. Such a child, in so far
as he or she is capable of receiving help from external sources (that is, help which
does not take into account unconscious conflicts) should be allowed to do all that
other children do, even when symptoms appear {e.g., feeling faint, pains, tiredness,
for instance) which would be enough to determine the sending of a rheumatic child
to bed for some months.
It is possible that nervous children are slightly more liable to rheumatic heart
disease than normal children; it is possible that excitable children are more liable
to chorea than their placid brothers and sisters. But there is certainly not enough
correlation to justify a general designation of nervous children as " pre-rheumatic "
or " pre-choreic." In this clinic these terms are never used, for they are not understood.
Rheumatism—Symptoms, etc.—The anxious child, especially when lying awake
for hours each evening, waking up with frequent nightmares and generally lacking
proper rest, is liable to " rheumatism "—that is, to pains in the thighs, back, head,
muscles and sometimes joints. These pains are similar to those which are often
acknowledged by a patient with definite rheumatic heart disease when questioned
with regard to his or her past history. In any one patient it is impossible to form