View report page

93
Dr. Thomson describes the rheumatic child as " thin, anremic and nervous ; commonly sleep is
broken, and often there are night ' terrors.' The appetite is usually poor. From time to time the
child complains of vague pains (growing pains) in the joints or in the muscles, which are frequently
brought on by exercise or by a change in the weather. This state of vague and ill-defined persisting
ill-health is marked at intervals by the occurrence of feverish sore throats (frequently called ' colds'
by the parents) or by the outbreak of obvious chorea. At any stage of the disease signs of cardiac
involvement may be found."
Acute Rheumatism (Rheumatic Fever) does occur in children but rarely in the form which the infection
commonly takes in adults. Its characteristics, including high fever and swollen acutely painful joints, bring the
cases under medical supervision. There is a marked tendency for inflammation of the heart and valves to develop
during the course of the attack, and the after-care of the patient is of great importance. This is to secure that
disease process in the heart is no longer active, and to adjust the patient's activities to the heart's capabilities. Unlike
most acute fevers, in which one attack confers immunity, there is a definite liability to recurrence, when progressive
deterioration of the heart is prone to occur.
Chorea.—The fully developed signs of this manifestation of rheumatism are familiar to most
people as "St. Vitus' Dance "—irregular involuntary movements of the face, limbs and trunk. But
before the development of these symptoms there is in most cases a period, perhaps of some weeks, when
definite though subtle changes in the child's disposition and behaviour should call the attention of the
parent or teacher to the fact that it is unwell.
Thomson describes the first change noticed as " general nervousness " with a loss of power of
concentration.
" The artisan mother notices that her girl becomes fidgety, dissatisfied and unable to settle to anything for
more than a few minutes : usually, however, the child makes no complaint and no importance is attached to the
observation until fresh attention is drawn to it by complaints from the school teachers that the child, although
apparently quite well, is inexplicably failing in her work ; first in application—' she sits dreaming away taking no
notice of anything or anyone around her '—as one teacher would put it, and then in execution. Handwriting suffers
early and it is an interesting and instructive thing to look over the exercise books of a schoolgirl who has developed
chorea. Often I have found that the neatness and clearness of the writing have given place to slovenly untidiness
before any suspicion of the onset of chorea has been entertained. Too often choreic children in the early stages
are punished in school before thej' are treated by their doctors. The appearance of the face alters soon ; the brisk,
alert expression of the normal child gives place to one of dull and apathetic stupidity."
He believes that if suitable treatment could be instituted early in this stage a large number of
attacks of chorea could be avoided or at all events reduced in severity and duration.
And the development of the case is thus pictured by Dr. Allan Warner :
" The face and hands should be watched to see if there are any slight irregular movements, especially about
the angles of the mouth and eyes. As the disease progresses, the muscles of the eyes may be involved, leading to
squint and double vision. Reading is often difficult. Another important symptom is loss of muscular power.
This is generally noticeable a short time after the beginning of the choreic movements, and later an arm may hang
loosely by the side or leg be dragged in walking. A further symptom is lack of co-ordination of voluntary movements
rendering the child awkward and clumsy. This condition is often the first to attract the parents' attention
and they complain that the child has become careless and is constantly dropping and breaking glass and crockery.
Such acts as dressing, writing or playing the piano are performed in an erratic manner. A good test for this
condition is to see if the child can pick up a pin or some small object from the floor, when the hand will be seen
to overshoot the mark in the attempt. During an attack of chorea the child is unusually pale and of rather a
mournful appearance, loses appetite and is depressed in spirits. There is often loss of memory and sleeplessness.
At the same time the physician may find evidence of heart disease."
The Pathology of Rheumatism.
A few words only are required here to describe the mechanism of the intimate action of the rheumatic infection
upon the tissues, and the response evoked therein.
During the active phases of the disease characteristic inflammatory nodules of microscopic size, shewing an
organisation of cells of constant types, may be found arranged around small vessels in widely scattered parts of the
body. These nodules presumably are found around the infective organism or substances carried from active rheumatic
foci, such as diseased tonsils. In process of time these nodules are replaced by minute scars. Such scars
do little harm in tissues like the skeletal muscles and the joints. But " if the poison attacks the noble tissues, the
muscles or nerves of the heart—this cannot be replaced if destroyed, and if they are partially damaged can only
recover completely if that damage be slight. When the fibrous tissues of the heart's framework, the valves, and the
pericardium, are attacked and destroyed, they are replaced by scar tissue, and if they are the seat of prolonged
irritation short of destruction they thicken and contract."
The heart endeavours to compensate for mechanical disadvantages imposed by such injuries with its reserve
power, and if they are healed lesions, i.e., if the rheumatic infection is dead, it may continue to be capable of meeting
reasonable demands made upon it for an indefinite number of years. " In fact, should symptoms of heart
failure be found in the young some degree of active infection is almost constant. It is an axiom that the chief cause
for a cardiac breakdown in a child is active—I do not say fresh—infection.
" I do not think we can ever get a real grasp of the problem of prevention unless we keep these two classes
of injury before our mind, for it is injury to the muscle of the heart which particularly calls for prolonged supervision
in convalescence, and the scarred valves disturb the work of the heart as a mechanical pump."—(Dr. F. J.
Poynton.)
Measures of Control.
I. Prevention.
This is the ultimate goal, but at present owing to the relative ignorance of medical science the
measures possible are in part experimental and of uncertain value. They may be deduced from a
consideration of the contributary factors :—
(1) Improve the condition of damp houses.—Avoid especially dampness in the sleeping quarters
of children of school age. This is an important aspect of the question of housing which
cannot be enlarged upon here.
(2) Maintain dry schools.—Dry premises, dry clothing and footwear of the scholars. The
importance of sound boots and facilities for drying damp clothes and boots in school