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39
œdema. Perry explains this by assuming a change in the plasma proteins coincident
with the oedema, and there is abundant evidence that these play an important part
in the sedimentation rate of the blood.
Thus it will be seen that, of the 9 cases in which there was evidence of activity
with a normal E.S.R., 7 cases had chorea only—no carditis or other rheumatic
manifestation. And of the 2 cases in which carditis was present, in one the activity
of the rheumatism was not definitely established, and in the other congestive oedema
was present.
The 76 cases, in which clinical evidence of activity was combined with a raised
E.S.R. reading over a definite period, have been divided into three groups according
to their activity as judged by the ordinary clinical standards.
Group “A” were very active cases. These numbered 27. In all these cases,
with the exception of one, the E.S.R. readings were over 50; and in all of them the
readings were over 40. The clinical evidence of activity was based on the following
considerations:—
(1) Pulse rate.—(a) During the day. In all the cases in this group the pulse
rate taken when the child was awake, but at rest during the day, was between
110 and 142. In 9 cases out of the 27 it was over 130 ; and in only 5 cases
was it less than 118.
(b) During sleep. The sleeping pulse rate in this group varied between
80 and 122.
(2) Temperature.—This was raised in 20 cases out of the 27. In 17 cases
there was an evening temperature of 100° or higher. In 3 cases there was an
evening temperature which varied between 99° and 100°. The 7 remaining
cases were afebrile.
(3) Cardiac change.—(a) The appearance of a murmur. An apical systolic
murmur, which was conducted out into the axilla, appeared in each case in this
group. In 9 cases a double mitral murmur was present, and in 4 cases a presystolic
murmur was associated with a pre-systolic thrill. In 5 cases both
mitral or aortic lesions were present.
(b) Cardiac enlargement. This was present in 23 cases.
(c) Pericarditis was present in 5 cases.
(4) Arthritis occurred in 12 cases out of the 27 in this group.
(5) Muscular pains were present in 5 cases.
(6) Active chorea was not present in any of the cases in this group.
(7) Rheumatic nodules were not to be found in any of the 246 cases upon
which the E.S.R. was periodically carried out, although a careful search was
made for them at each routine examination.
(8) An erythematous eruption developed in 1 case.
(9) Loss of weight.—This could not be estimated in most of the cases in this
group as the majority of the cases were admitted as recumbent cases with
definite signs of activity and were put to bed without being weighed. In 2
cases, however, the activity recurred while the patient was at High Wood and
has now ceased, and in both these cases loss of weight has been found to have
taken place.
Group “B” were moderately active cases. These numbered 16. In 14 of
these cases the E.S.R. readings varied between 18 and 55. In 2 cases they were
over 100. The clinical evidence of activity, based on the same considerations as in
group “A” was as follows:—
(1) Pulse rate.—(a) During the day. The pulse rate taken with the child
at rest during the day varied between 100 and 110 in the cases in this group
with the exception of two cases, when it was 122 and 128 respectively.
(b) During sleep. The pulse rate varied between 80 and 90, with the
exception of the same two cases, in each of which it was 100.