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39
sub-acute rheumatism of four, five and seven years' duration, while some of the
choreic cases had had attacks of sub-acute rheumatism for as long as seven years.
Nor is the story of the sub-acute form of the disease told when its tendency to
pass into an acute stage or to initiate cardiac disease has been noted. As Dr. Sheldon
has recently emphasised, many children who have every symptom of sub-acute
rheumatism when examined in their homes or in the out-patient department of a
hospital exhibit no sign of it while resident in a hospital or convalescent home. It
would be easy to be satisfied with the conclusion that these children have never had
sub-acute rheumatism and that their admission to hospital was due to a mistake in
diagnosis. Unfortunately the subsequent history of these children does not confirm
this view for, at a later date, the symptoms of rheumatism reappear. A girl is at
present under consideration for hospital treatment who has twice before spent some
months in hospital. On neither occasion had she any symptom of active rheumatism
while in hospital.
The most cheering aspect of the question is the changed attitude of the parents
towards mild attacks of rheumatism. At lectures to parents, and at interviews in
their homes they show themselves keenly appreciative of the cardiac menace of
rheumatism. This is to be attributed to the increased interest which the assistant
medical officers working in the schools are taking in the disease, to the patient,
painstaking pioneer work of the rheumatism supervisory centres, and to the influence
in the homes of the school care committee visitors. Even with the increased number
of beds available this year it has been impossible to meet the demands of parents for
treatment for their children.
Parental
attitude.
The children, who are examined on their return from treatment at Carshalton
or Brentwood, are bronzed and well, and all symptoms of rheumatism have
disappeared. The reports from the assistant medical officers on the special
examinations of these children in school, over a year or two, show that the majority
of them do not need further residential treatment, although many of the children
have mild attacks of rheumatism which can be treated at home under medical
advice. The question naturally arises how far the prolonged course of treatment
adopted at Carshalton or Brentwood compares in its results with the shorter
residential treatment provided by other hospitals, or that given at the out-patient
departments. There were no data to answer this question until Dr. Warner recently
threw some light on the matter. After pointing out that the cases sent to Queen
Mary's Hospital, Carshalton, were initially more severe than those treated by other
methods, he states that the relapses in the first three years are only half the number
met with in cases which have not had prolonged institutional treatment. There
appears no reason why such commendation should not equally apply to the work at
High Wood Hospital, Brentwood.
Results of
prolonged
hospital
treatment.
Since the inauguration of the scheme 128 children treated in hospital have relapsed
sufficiently to need further hospital treatment. Of these 28 had been removed
from hospitals by their parents before the completion of their treatment. The
remainder were:—
Rheumatism 37
Rheumatism with heart disease 31
Chorea 28
Chorea and heart disease 4
100
Relapses.
There are so many factors which may have an influence in bringing about the
recrudescence of the various manifestations of the rheumatic infection that an
enquiry as to the causes of relapse ends in the " might " and the " may."
It has been thought, for example, that the length of time which a child remains
in hospital influences the chances of a recurrence. The average stay of the above
children in hospital was 29 weeks, which is a lengthy stay for cases many of which
had already had treatment in some other hospital before being sent to Queen Mary's
or High Wood. Moreover the stay of these children compares favourably with that
of the children who have not relapsed sufficiently to need once again hospital
treatment.