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A few succumb from hearts afflicted at the time of an attack of pneumonia, diphtheria, or
other acute infection, or from some chronic infection of teeth or bowel.
Thus, whilst there is undoubtedly opportunity through the practice of personal hygiene of
postponing many of these deaths to a riper old age, it may be said that many of them have accomplished
a long span of years and for the rest some fall prematurely through their own folly.
Statistics derived from the School Medical Service.—It might be supposed that data available
from all parts of the country derived from the periodical examination of school children, and the
ascertainment of the disability which keeps children away from school for long periods (thus not
finding their way to medical inspection) would admit of a general estimate of the extent of rheumatic
infection amongst children of school age. But as Thomson has justly observed : "The statistics
of the school medical service are vitiated by the fact the conditions of inspection do not, in general,
permit of very exhaustive examination of the individual child, and inasmuch as the signs of rheumatism
and early heart diseases are frequently unobtrusive, it. is probable that many of the cases
are missed, or are simply placed in such categories as ' malnutrition,' ' anaemia ' or ' functional
afflictions.' "
Bearing this source of error in mind, it is yet helpful to note such facts as the following :—
In his report for 1925, the School Medical Officer of the London County Council wrote :
" From reports made by the school doctors it may be computed that there are in the London area certainly
not less than 10,000 children who have suffered or are suffering from rheumatic symptoms. The great majority
of these, of course, are not in need of any special treatment other than that they are already receiving, but they
require careful watching. They are mostly attending school, and under the observation of the school medical service,
and are known to the school care committees, who give the parents such advice and help as is, from time to time,
desirable. There are about 1,000 of these children attending special (physically defective) schools whose hearts have
been seriously and permanently injured ; and there are from 600 to 700 children absent from school for long periods
on account of rheumatism. These last represent 25 per cent, of the chronic invalidity amongst children, and include
all, or almost all, the children for whom special arrangements are still necessary."
Researches undertaken by School Medical Officers in different areas during the last few years
present figures not wholly comparable since some estimate the total volume of rheumatic cases in the
school population examined, others the total volume of organic heart disease (made up chiefly of the
most significant end-results of rheumatism) similarly found, whilst others discriminate between the
numbers found at the three statutory age groupings—entrants, intermediates, and leavers.
The prevalence of rheumatism would, from these scattered findings, appear to vary widely,
and in some areas an alarmingly high proportion of the children examined were found to be infected.
Thus, from Wigan, in 1919, is reported 21 per cent, of rheumatic children out of 1,211 examined ;
from Cheshire, in 1920-1921, is reported 10 per cent, of the children attending the elementary schools ;
whilst at Rhondda, in 1923, out of 5,000 examined 15-8 per cent, were rheumatic.
Of equal or greater significance is the emergence of another fact—that far more cases are
found amongst the older children than amongst the younger ; in other words, that the disease develops
whilst the children are at school. Thus at Crewe, in 1924, amongst entrants 2-5 per cent., intermediate
children 5-6 per cent., and leavers 15 per cent, were rheumatic. At Bath Dr. Thomas found
the incidence of organic heart disease among 8,653 children examined at ordinary routine medical
inspection to be : entrants 1 00 per cent., intermediates 0-98 per cent., leavers 2-36 per cent.
The Manifestations of Rheumatism.
It cannot be too emphatically stated that the typical rheumatic infection in children is a slow
insidious process, whose existence is frequently not recognised—because the symptoms and signs
are overlooked or misinterpreted—until permanent damage has been done to the heart. This subacute
or chronic rheumatism manifests itself in many different ways, which may appear in one composite
picture or more usually one or two features only are present at one time.
It may be visualised as—
(1) An infection smouldering in chronically diseased tonsils, and occasionally lighting up in
them a more or less acute tonsillitis.
(2) A state of mild intoxication due to the growth of the organism in the tonsils or other organs,
revealed by undefined ill-health, pallor (due to blood destruction), loss of weight or failure to gain
weight, undue excitability or depression, slight irregular fever.
(3) An infection smouldering in heart muscle and heart valves, often with no symptoms in the
early stages and unsuspected unless sought for. It may pass off without detectable permanent
damage to the heart, or it may lead to valvular disease, hypertrophy and dilatation, or it may be so
severe as to cause early cardiac failure.
(4) An affection of the brain, chorea (St. Vitus's dance) of no permanent importance in itself
(except in very rare cases), but it prevents schooling, and indicates the danger of accompanying heart
affection, and therefore compels treatment.
(5) Minor effects, signifying infection of fibrous tissue only, but of diagnostic import:—
" Growing pains," not well localised, and usually related to the arms and legs ; painless fibrous
nodules found fixed to the bones about the joints, over which the skin moves freely ; and skin
eruptions.
In a recent study of rheumatic infection in 141 children, Dr. Mary Bertram, of Glasgow, has estimated
that the onset of the disease occurred in 60 per cent, of her cases at ages from 6-10 years ; that girls were more
frequently affected than boys ; that 76 per cent, of her patients suffered from carditis, 73 per cent, from arthritis,
47 per cent, from chorea, 28 per cent, from tonsillitis, and 7 per cent, from subcutaneous nodules. Dr. Poynton
on the other hand finds from a record of 1,108 probable first attacks of acute rheumatism under twelve years of age
that 60 per cent, suffered from carditis, 56 per cent, from arthritis and 55 per cent, from chorea, with only some
8 or 9 per cent, having subcutaneous nodules.