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even an opinion as to the etiology of pains without swelling unless the type of child
is known.
If the illness with pains occurs in acute attacks with feverishness, and with first
one and then another joint definitely picked out, especially if the child is not over
nervous as far as can be judged, then the presumption of real sub-acute rheumatism
is stronger.
The occurence of hot, shiny, swollen joints is taken as evidence that the subacute
illness is rheumatic and liable in this or a subsequent attack to be associated
with heart disease, provided that other joint infections (e.g., pyogenic, tuberculous)
can be ruled out. It is characteristic for the swelling to flit from joint to joint in
rheumatism.
A form of insidious rheumatic fever is repeated tonsillitis, or faucitis after
tonsillectomy. There are physicians who recognise a rheumatic type of tonsil;
this has not been found possible here. Acute rheumatism is at the time often fairly
easy to diagnose, and is not especially under review in this context.
Heart disease accompanying rheumatism.—Heart disease of undoubted rheumatic
nature may be found without any history of rheumatism whatever. On the
other hand, a child may suffer from many attacks of typical acute rheumatism and
yet never develop heart disease. It is common for several attacks of rheumatism
or chorea to occur in a patient before one in which the heart becomes involved.
There are some who consider that every attack of rheumatism is accompanied
by heart muscle disease, even if no signs of disease remain after recovery. The
important factor is certainly the state of the heart muscle, and it is very difficult to
exclude heart muscle involvement in a case of definite rheumatism. It is a good
treatment, therefore, to treat every case which has been diagnosed as rheumatic by
complete rest, even when the heart is not obviously involved in this particular attack.
It is fairly clear, however, that there are definite rheumatic attacks without
heart involvement, and any test which would distinguish these attacks from those
with heart involvement would be of great value. There is no such test at present.
In difficult cases the physician has to rely on the impression he forms after enquiry
into the type of child and careful examination. (See paragraphs on " active heart
disease.")
When old rheumatic disease of the heart is present the physician is justified in
saying that as the child has had some form of rheumatism he or she is liable to the
same again. In an otherwise doubtful case of sub-acute rheumatism, the presence of
old heart disease would weigh down the balance on the side of rheumatism. The
presence or absence of active heart disease cannot, however, be decided on these
points. Whether the patient has had heart disease or no, the diagnosis of active
heart disease must be made with reference to the present condition of the child as an
active being.
Active rheumatic heart disease.—The centre point round which all the work
of a supervisory clinic revolves is the diagnosis of active heart disease. There are
certain signs of acute carditis in an ill child that make diagnosis comparatively
easy. The dilatation and a rapid rate not properly accounted for by the raised
temperature, lead the way to a recognition of the condition of rheumatic carditis,
even when no changing sounds point to active disease of the valves. When pericarditis
is present diagnosis is still further facilitated.
In the child thought to be suffering from sub-acute rheumatism, however, the
diagnosis of active smouldering carditis is excessively difficult. The condition
undoubtedly occurs, many diseased hearts having become diseased during a period
of sub-acute rheumatism without acute attacks. There may be times when in our
ignorance we decide for or against diagnosis of rheumatism according to the opinion
we form as to the presence or absence of carditis.
From time to time tests are brought forward as capable of deciding or materially