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ACUTE RHEUMATISM AMONG CHILDREN: AN INQUIRY INTO THE PREVALENCE OF ACUTE RHEUMATISM AND ITS CONSEQUENCES AMONG CHILDREN OF SCHOOL AGE.
1133 on the senile condition of the uterus. I know that torsion of the pedicle of a stalked fibroid will lead to very acute symptoms, for I exhibited and described such a specimen(which is also preserved in the Museum of the Royal College of Surgeons of England) in which they were as severe as any I have noticed in association with ovarian cysts and tumours, and in spite of the fact that the fibroid was partially calcified. Cases have been reported in which an ovarian cyst with a short broad pedicle has rotated and involved the uterus in the twist. In such a case the conditions would be almost parallel to those prevailing in the patient the subject of this communication. All in all, I am sure that the axial rotation of a uterine fibroid above the size of a walnut is a rare accident.
symptoms depended
,
make the same inquiries. This article is based on the data so obtained. Nm-ntber (If .Definitely Rheumatio Ohildren. Fifty-nine boys and 74 girls could be classified as definitely rheumatic, a total of 133. This is equivalent to a percentage incidence of 5 20 for children of all ages attending school, or of 6-83 for children in the senior departments only, those attending the infants’ department being excluded from the estimation. The number affected at the different ages, and the percentage of rheumatic children at each age,.are best shown in the accompanying table :-
Brook-street, W.
ACUTE RHEUMATISM AMONG CHILDREN: AN INQUIRY INTO THE PREVALENCE OF ACUTE RHEUMATISM AND ITS CONSEQUENCES AMONG CHILDREN OF SCHOOL AGE. BY FREDERICK LANGMEAD, M.D. LOND., M.R.C.P. LOND., ASSISTANT PHYSICIAN, ROYAL FREE AND SEAMEN’S HOSPITALS; AND PHYSICIAN TO
OUT-PATIENTS, PADDINGTON GREEN CHILDREN’S HOSPITAL.
IT is uttering
a platitude to say that acute rheumatism is of the commonest diseases of children which the medical Yet the incidence among the man is called upon to treat. community at large of a particular affection is often erroneously estimated by those who see only sick patients in hospital or elsewhere. The proportion of rheumatic children attending hospital to those suffering from other diseases is, without doubt, an index of the gravity of the infection, but it gives no guide to the amount of detectable rheumatism, or to the frequency of defects consequent on rheumatism, which may be present in those considered A good example of the at the time to be in good health. discrepancy between conclusions based on hospital figures and those obtained by the examination of school children is found in the case of tuberculosis, for this disease, though very prevalent among hospital children, is rarely detected in the examination of children at school ; so rarely, indeed, that out of 1670 unselected school children examined by Dr. J. E. Squire and Dr. Annie Gowdey only 4’4 per 1000 were found to be definitely tuberculous. Remembering this and similar discrepancies, I have endeavoured to temper my views gleaned from hospital experience by an inquiry into the amount of detectable rheumatism among children attending the ordinary elementary schools of the London County Council. Altogether 2556 children have been examined in four schools. These were in no sense selected. In three of the schools every child was examined ; in the other, children who had arrived at certain periods of their school life were examined in accordance with the requirements of the education service. Of the total 2556, 844 were boys and 838 girls in the senior departments -i.e., from 6-2L to 14 years old; and 874 were attending the infants’ department, and consisted of nearly equal numbers of boys and girls from 3 to 6 years old. Method of ’P’J"ooed1/1J’e. -Each child was stripped to the waist, and the heart was carefully examined by the usual methods, any deviation from the normal either in size or action being noted. Other evidences of rheumatism were looked for. The size of the tonsils was recorded in figures, +1implying slight enlargement, z- 2 considerable enlargement, and + 3 very great enlargement. If adenoids were present in the absence of enlarged tonsils and were sufficient to cause signs of obstructed breathing, this observation was also noted down. An inquiry was made of the child, and of the m ’ther when she was in attendance, for previous rht nmatic manifestations in the child or for rheumatism in the family. When from the examination it seemed probable that the child was the subject of rheumatism, if the mother was not present, a nurse afterwards called at the home to
one
1
Transactions of the Obstetrical
Society, 1904,
vol. xlvi., p. 149.
* The number of children at the ages of 3 and 14 was too small to work out a percentage incidence of rheumatism which would be even approximately correct.
In the majority of cases attention was drawn to the rheumatic child by the condition of the heart-sometimes by definite valvular disease, at others by dilatation accompanied by such alteration in sounds and rhythm as one is accustomed to hear in rheumatic children. I need scarcely say that dilatation, weak cardiac sounds, or arrhythmia, by themselves were not accepted as sufficient evidence of active or past rheumatism ; but children showing such manifestations were only accounted rheumatic if there was strong enough collateral evidence to remove all reasonable doubt. For example, a little boy aged 7 years was found to have a deep cardiac dulness reaching nearly 2 inches outside the left nipple line, and weak cardiac sounds unaccompanied by a bruit ; he was only considered rheumatic because it was elicited that he had been subject to growing pains, his brother had had rheumatic fever twice, chorea, and tonsillitis, and his mother chorea. Another patient, a girl aged 9 years, who had fainted frequently and whose heart missed one beat in about every four, was included among the rheumatic cases, because she had had frequent tonsillitis and both her mother and brother had had rheumatic fever. By requiring such definite evidence as this it is clear that one is likely to include too few rather than too many cases. Again, there are some rheumatic manifestations which, although very common, cannot be ascribed with certainty to rheumatism, in the absence of other data. Acasmia, for example, although an important and common consequence of rheumatism, and probably often occurring alone as the result of that disease, would not under those circumstances be recognised as rheumatic in origin. The same may be said of tonsillitis. Growing pains also, although undoubtedly rheumatic, make so little impression on the parents and are so readily forgotten or confused with the vague pains which herald or follow other acute febrile disturbances, that a of their occurrence cannot be accepted as adequate evidence of rheumatism. Yet it is probable that growing pains not infrequently form the only manifestation of rheumatism in childhood. For these reasons it is almost certain that the percentage I have given above is well within the mark. The table shows, broadly speaking, that more and more children become rheumatic as they grow older. There is, however, an apparent accession of rheumatism at the age of 10 which is not shown in the figures in subsequent years. I can give no explanation for this, and regard it as an inaccuracy which would have disappeared if a large enough number of children had been examined.
history
Inaidenoe of Rheumatio Beart 9"’eetions. I found that out of 133 children whom I had been able to classify as rheumatic, all except 18 showed some evidence of cardiac disorder at the time of examination. Thus rheumatic. heart affection occurred in 4’ 49 per cent. of the children of all ages attending school, or in 5-94 per cent. of those in the senior departments only. Obvious valvular disease was found in 2- 93 per cent. of children at all ages, or 3-92 per cent. of those in the senior departments.
1134 rheumatic
cases.
This
interference in 37 cases,
sufficient to warrant operative 27’88 per cent. of the rheumatic
was or
cases.
It is
interesting to compare these figures with those indithe average frequency of tonsils and adenoids in school children generally. According to Macleod Yearsley, 7 per cent. of all school children require operation for this condition, whilst the medical officer of the Board of Education, from the results of the examination of 5,000,000 children, found that the percentage came out at 8. Therefore the incidence of tonsils and adenoids large enough to require operation is nearly four times as great in rheumatic children as in school children generally. Whether the abnormal tonsils permit the ingress of the rheumatic microorganism, or whether they are the result of rheumatic tonsil. litis, is a question which cannot be answered at present.
cating
The comparative rarity of aortic regurgitation in children is emphasised by the fact that only one case was discovered among the 2556 children examined. It will be observed that I have hesitated to group those children whose hearts were dilated and in whom only slight - B6?K
ACUTE ENDOCARDITIS CAUSED BY A MICRO-ORGANISM HITHERTO UNDESCRIBED. No reliable data
were
obtained in 10
cases.
As has been stated above, the percentage of the fleeting and consequently easily forgotten forms of rheumatism is probably far below the true average, whilst no data of value could be obtained of certain rheumatic manifestations like anaemia. Enlarged tonsils and adenoids.-The relation of enlarged tonsils and adenoid vegetations to rheumatism in childhood is well illustrated by the figures obtained. Taking the 133 rheumatic cases, in 75 there were no signs of abnormality in the throat, in 21 the tonsils were slightly enlarged, in 11 considerably enlarged, in 16 greatly enlarged, and in 3 tonsillotomy had been performed before the patients were examined. Adenoids were responsible for producing signs of post-nasal obstruction and mouth-breathing in 7. In other words, there was an abnormality of the tonsils or pharyngeal mucosa or both in 58 cases, or in 43 6 per cent. of the
BY A. T.
NANKIVELL, M.D., B.S. LOND., L.R.C.P. LOND., M.R.C S. ENG., D.P.H. CAMB.,
ASSISTANT MEDICAL OFFICER, CROYDON BOROUGH HOSPITAL ; AND DEMONSTRATOR IN PUBLIC HEALTH LABORATORIES, KING’S COLLEGE, UNIVERSITY OF LONDON.
A LITTLE girl, 32 years old, was admitted to the Croydon Borough Hospital on Feb. 1st of this year. She was suffering from a mild attack of scarlet fever without severe throat symptoms. Her illness ran a normal course towards convalescence. But three weeks after admission she began to have rises of temperature in the evenings. At first the heart sounds were natural; later she developed a slight but definite double mitral murmur ; the heart was appreciably enlarged. During the first week in March the temperature oscillated between 990 and 101° F. There was no splenic enlargement nor any sign of infarction elsewhere; the patient had nojoint pains, nor were there any rheumatic
symptoms depended
,
make the same inquiries. This article is based on the data so obtained. Nm-ntber (If .Definitely Rheumatio Ohildren. Fifty-nine boys and 74 girls could be classified as definitely rheumatic, a total of 133. This is equivalent to a percentage incidence of 5 20 for children of all ages attending school, or of 6-83 for children in the senior departments only, those attending the infants’ department being excluded from the estimation. The number affected at the different ages, and the percentage of rheumatic children at each age,.are best shown in the accompanying table :-
Brook-street, W.
ACUTE RHEUMATISM AMONG CHILDREN: AN INQUIRY INTO THE PREVALENCE OF ACUTE RHEUMATISM AND ITS CONSEQUENCES AMONG CHILDREN OF SCHOOL AGE. BY FREDERICK LANGMEAD, M.D. LOND., M.R.C.P. LOND., ASSISTANT PHYSICIAN, ROYAL FREE AND SEAMEN’S HOSPITALS; AND PHYSICIAN TO
OUT-PATIENTS, PADDINGTON GREEN CHILDREN’S HOSPITAL.
IT is uttering
a platitude to say that acute rheumatism is of the commonest diseases of children which the medical Yet the incidence among the man is called upon to treat. community at large of a particular affection is often erroneously estimated by those who see only sick patients in hospital or elsewhere. The proportion of rheumatic children attending hospital to those suffering from other diseases is, without doubt, an index of the gravity of the infection, but it gives no guide to the amount of detectable rheumatism, or to the frequency of defects consequent on rheumatism, which may be present in those considered A good example of the at the time to be in good health. discrepancy between conclusions based on hospital figures and those obtained by the examination of school children is found in the case of tuberculosis, for this disease, though very prevalent among hospital children, is rarely detected in the examination of children at school ; so rarely, indeed, that out of 1670 unselected school children examined by Dr. J. E. Squire and Dr. Annie Gowdey only 4’4 per 1000 were found to be definitely tuberculous. Remembering this and similar discrepancies, I have endeavoured to temper my views gleaned from hospital experience by an inquiry into the amount of detectable rheumatism among children attending the ordinary elementary schools of the London County Council. Altogether 2556 children have been examined in four schools. These were in no sense selected. In three of the schools every child was examined ; in the other, children who had arrived at certain periods of their school life were examined in accordance with the requirements of the education service. Of the total 2556, 844 were boys and 838 girls in the senior departments -i.e., from 6-2L to 14 years old; and 874 were attending the infants’ department, and consisted of nearly equal numbers of boys and girls from 3 to 6 years old. Method of ’P’J"ooed1/1J’e. -Each child was stripped to the waist, and the heart was carefully examined by the usual methods, any deviation from the normal either in size or action being noted. Other evidences of rheumatism were looked for. The size of the tonsils was recorded in figures, +1implying slight enlargement, z- 2 considerable enlargement, and + 3 very great enlargement. If adenoids were present in the absence of enlarged tonsils and were sufficient to cause signs of obstructed breathing, this observation was also noted down. An inquiry was made of the child, and of the m ’ther when she was in attendance, for previous rht nmatic manifestations in the child or for rheumatism in the family. When from the examination it seemed probable that the child was the subject of rheumatism, if the mother was not present, a nurse afterwards called at the home to
one
1
Transactions of the Obstetrical
Society, 1904,
vol. xlvi., p. 149.
* The number of children at the ages of 3 and 14 was too small to work out a percentage incidence of rheumatism which would be even approximately correct.
In the majority of cases attention was drawn to the rheumatic child by the condition of the heart-sometimes by definite valvular disease, at others by dilatation accompanied by such alteration in sounds and rhythm as one is accustomed to hear in rheumatic children. I need scarcely say that dilatation, weak cardiac sounds, or arrhythmia, by themselves were not accepted as sufficient evidence of active or past rheumatism ; but children showing such manifestations were only accounted rheumatic if there was strong enough collateral evidence to remove all reasonable doubt. For example, a little boy aged 7 years was found to have a deep cardiac dulness reaching nearly 2 inches outside the left nipple line, and weak cardiac sounds unaccompanied by a bruit ; he was only considered rheumatic because it was elicited that he had been subject to growing pains, his brother had had rheumatic fever twice, chorea, and tonsillitis, and his mother chorea. Another patient, a girl aged 9 years, who had fainted frequently and whose heart missed one beat in about every four, was included among the rheumatic cases, because she had had frequent tonsillitis and both her mother and brother had had rheumatic fever. By requiring such definite evidence as this it is clear that one is likely to include too few rather than too many cases. Again, there are some rheumatic manifestations which, although very common, cannot be ascribed with certainty to rheumatism, in the absence of other data. Acasmia, for example, although an important and common consequence of rheumatism, and probably often occurring alone as the result of that disease, would not under those circumstances be recognised as rheumatic in origin. The same may be said of tonsillitis. Growing pains also, although undoubtedly rheumatic, make so little impression on the parents and are so readily forgotten or confused with the vague pains which herald or follow other acute febrile disturbances, that a of their occurrence cannot be accepted as adequate evidence of rheumatism. Yet it is probable that growing pains not infrequently form the only manifestation of rheumatism in childhood. For these reasons it is almost certain that the percentage I have given above is well within the mark. The table shows, broadly speaking, that more and more children become rheumatic as they grow older. There is, however, an apparent accession of rheumatism at the age of 10 which is not shown in the figures in subsequent years. I can give no explanation for this, and regard it as an inaccuracy which would have disappeared if a large enough number of children had been examined.
history
Inaidenoe of Rheumatio Beart 9"’eetions. I found that out of 133 children whom I had been able to classify as rheumatic, all except 18 showed some evidence of cardiac disorder at the time of examination. Thus rheumatic. heart affection occurred in 4’ 49 per cent. of the children of all ages attending school, or in 5-94 per cent. of those in the senior departments only. Obvious valvular disease was found in 2- 93 per cent. of children at all ages, or 3-92 per cent. of those in the senior departments.
1134 rheumatic
cases.
This
interference in 37 cases,
sufficient to warrant operative 27’88 per cent. of the rheumatic
was or
cases.
It is
interesting to compare these figures with those indithe average frequency of tonsils and adenoids in school children generally. According to Macleod Yearsley, 7 per cent. of all school children require operation for this condition, whilst the medical officer of the Board of Education, from the results of the examination of 5,000,000 children, found that the percentage came out at 8. Therefore the incidence of tonsils and adenoids large enough to require operation is nearly four times as great in rheumatic children as in school children generally. Whether the abnormal tonsils permit the ingress of the rheumatic microorganism, or whether they are the result of rheumatic tonsil. litis, is a question which cannot be answered at present.
cating
The comparative rarity of aortic regurgitation in children is emphasised by the fact that only one case was discovered among the 2556 children examined. It will be observed that I have hesitated to group those children whose hearts were dilated and in whom only slight - B6?K
ACUTE ENDOCARDITIS CAUSED BY A MICRO-ORGANISM HITHERTO UNDESCRIBED. No reliable data
were
obtained in 10
cases.
As has been stated above, the percentage of the fleeting and consequently easily forgotten forms of rheumatism is probably far below the true average, whilst no data of value could be obtained of certain rheumatic manifestations like anaemia. Enlarged tonsils and adenoids.-The relation of enlarged tonsils and adenoid vegetations to rheumatism in childhood is well illustrated by the figures obtained. Taking the 133 rheumatic cases, in 75 there were no signs of abnormality in the throat, in 21 the tonsils were slightly enlarged, in 11 considerably enlarged, in 16 greatly enlarged, and in 3 tonsillotomy had been performed before the patients were examined. Adenoids were responsible for producing signs of post-nasal obstruction and mouth-breathing in 7. In other words, there was an abnormality of the tonsils or pharyngeal mucosa or both in 58 cases, or in 43 6 per cent. of the
BY A. T.
NANKIVELL, M.D., B.S. LOND., L.R.C.P. LOND., M.R.C S. ENG., D.P.H. CAMB.,
ASSISTANT MEDICAL OFFICER, CROYDON BOROUGH HOSPITAL ; AND DEMONSTRATOR IN PUBLIC HEALTH LABORATORIES, KING’S COLLEGE, UNIVERSITY OF LONDON.
A LITTLE girl, 32 years old, was admitted to the Croydon Borough Hospital on Feb. 1st of this year. She was suffering from a mild attack of scarlet fever without severe throat symptoms. Her illness ran a normal course towards convalescence. But three weeks after admission she began to have rises of temperature in the evenings. At first the heart sounds were natural; later she developed a slight but definite double mitral murmur ; the heart was appreciably enlarged. During the first week in March the temperature oscillated between 990 and 101° F. There was no splenic enlargement nor any sign of infarction elsewhere; the patient had nojoint pains, nor were there any rheumatic