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than it was. It is interesting to note that the weather in 1950 was inclement. Whereas
1949 was characterised by long spells of fine weather, the summer and autumn of
1950 were damp and the humidity high.
Changes in methods of disposal of convalescent cases is probably a more potent
factor and a tendency for hospitals to keep their rheumatism cases and not inform
the school health service has been noted. But improvements in treatment of acute
infections of the upper respiratory tract must also be borne in mind.
In the days before sulphonamide therapy became prevalent (and with the
advent of more elegant and less toxic forms of the drug, this prevalence has been
enhanced) acute sinusitis and acute tonsillitis were severe diseases ushered in by
fever, tachycardia, toxaemia and fall of blood pressure in addition to the local signs.
The acute phase lasted for a week or ten days and was then followed by resolution
or sequelae such as peritonsillar abscess, antral empyema, otitis media or mastoiditis
or more remotely by articular rheumatic fever or carditis.
Of latter years, however, the picture has altered. Under sulphonamide and
penicillin therapy the period of convalescence begins within twenty-four to fortyeight
hours and the untoward effects mentioned above are now comparatively rare.
Admittedly during the last two decades scarlet fever has become a more benign
disease and the streptococcus haemolyticus is no longer so dangerous, so the decrease
in the number of nominations for institutional treatment may in part be a measure
of a real decrease in the prevalence of j uvenile rheumatism also. Certainly the number
of cases of rheumatic carditis applying for admission to schools for physically handicapped
children is also decreasing, and gradually the importance of congenital heart
disease is overshadowing that of rheumatic carditis.
The drop in nominations in 1949 which was maintained in 1950 seems to have
been too sudden, however, to be explained solely by improved treatment or
reduced incidence or virulence of streptococcal infection and we come back, therefore,
to the conclusion that alterations in the administrative activity and disposal of
the cases must have played a substantial part in its causation.
By far the most serious complication of rheumatic infection in children is
carditis. It is responsible for much crippling heart disease in later life, and preventive
work in this direction is bound to have a beneficial effect upon the health
and efficiency of the community at large. It is interesting to record that the Council's
rheumatism scheme started some 25 years ago with clinics for juvenile rheumatism
and developed therefrom hospital and clinic provision for carditis, whereas our American
colleagues, starting with the care of heart disease in children, have come to treat
juvenile rheumatism, so that working from opposite ends the schemes have eventually
covered much the same ground.
The preventive aspect of the juvenile rheumatism scheme is one that cannot
too often be stressed, for although many people regard recurrence of this disease as
something different from a first attack, yet time after time the same clinical features
are reproduced and, if the complete history of every case could be obtained, many
so-called first attacks would be found to be recurrences of infection. Many, of
course, are so mild that they go unrecognised. Sub-acute rheumatism can often be
overlooked, as it is in the nature of this disease to recur. If it is a smouldering
chronic infection, what causes it suddenly to light up ? Is it the sudden exaltation
of virulence on the part of the infecting organism ? Is there a diminished resistance
on the part of the host ? Does a change of environment stimulate or unmask a latent
toxaemia, or is it caused by an allergic response on the part of the child ? Wherein
lies this latent trigger action ? These are all questions which the physician in charge
of the rheumatism supervisory centre must bear in mind, and perhaps one or two
key discoveries in immunity may well uncover the tissue reaction involved in
rheumatic fever. We all await the results of further research in the use of A.C.T.H.
and Cortisone in the treatment of this symptom-complex.