RHEUMATIC CONDITIONS IN SCHOOL-CHILDREN.

720 below the patella ; that is to say, its distributionof X rays, repeated in three weeks’ time, is often does not follow that of a vascular supply or a lymphaticmagical in its effect. Continuance of irradiation is tract, or the distribution of a nerve. It correspondsto be deprecated, although patients will press for it. to that found in hysterical anaesthesia and contrastsRepeated exposure to X rays causes atrophy of the sharply with what is seen in true neuritis. It willskin, recognisable by white scarring dappled with often be found, on close inquiry, that the original pigmented spots andred blotchy vessels. Such spread of the eruption was due to the employment of atrophic skin is fragile and vulnerable, and in later strong mercurial ointments. If such patients are years is apt to undergo a malignant metaplasia. This admitted into hospital and their legs are dressed with sequence may be avoided by changing over to treatthe blandest applications and their hands are kept ment by ultra-violet light, which should be adminisfrom all contact, the superficial inflammation will tered in large doses, such as ten minutes of a Jesionek gradually subside, leaving pigmented, rather glistening lamp exactly to the affected area at a distance of one dry skin of a normal pattern. In these cases great foot ; this exposure may safely be repeated after a benefit is obviously obtained by the element of drama fortnight’s interval. In all these cases no general medical counsels should in treatment ; the paint known as Sir Lenthal Cheatle’s malachite green stings slightly when sprayed on the be overlooked. Bad habits of constipation must be skin and leaves a vivid green colour, which is very corrected and oral sepsis must be adequately treated. Malnutrition is often present owing to bad home satisfying to these self-centred people. Among nervous patients after the general eruption cooking. A mixture of iron, strychnine, and arsenic has faded an irritating reddened area of skin may be should be prescribed for the pallid town-worker, while left at the wrist or elbow ; this by prolonged rubbing the nervous, quick, and fretful patient, more than may become rough and thickened, standing out others, should be aided by the early administration of almost as a piece of shagreen leather in contrast with bromides in adequate doses. This patch of altered, but not the normal skin. W. J. O’DONOVAN, O.B.E., M.D. Lond., pathological skin, is apt to be fiercely irritable at Physician, Skin Department, London Hospital, fixed times and causes great depression. In such and St. Paul’s Hospital for Skin Diseases. circumstances one-third of a Sabouraud pastille dose

just

children in the usual way, except that in no case have I put either of the two usual questions : " Do you or " Do you have growing ever ache anywhere " ; pains ? " In these 200 children neither parent nor RHEUMATIC CONDITIONS IN SCHOOL- child has once mentioned growing pains, though in some cases I knew from other sources of information CHILDREN. that they existed. To obtain accurate information AN INVESTIGATION INTO GROWING PAINS AND NODULES the question must be put systematically to every child old enough to answer intelligently, or at least (GRAINS). to every parent. BY MARY F. WILLIAMS, M.B. LOND., D.P.H., It is sometimes said that children answer haphazard SENIOR ASSISTANT COUNTY MEDICAL OFFICER, WORCESTERSHIRE.when asked as to " growing pains," but this has not been my experience. In many cases a previous THE work here described is an endeavour to obtain record of them existed, unknown to the child, and definite statistical information in regard to growing the answers were almost always in accord. For pains " and the conditions correlated with them. instance, in one school, 11 children were investigated the examination, in 1926 and 1927, of 1298 in 1925, and again in 1926 or 1927. The children, During " routine " children over 8 years of age, in school, 7 in number, who stated they had growing pains special attention was paid to the following points : in 1925, gave the same answers, 3 in 1926, and 4 (1) growing pains ; (2) condition of teeth ; (3) condition in 1927. Four children, in 1925, stated that they of tonsils ; (4) cardiac conditions ; (5) existence of had not had growing pains, and of these 3 gave the nodules or grains. same answers in 1926, and 1 stated he had had them It is difficult to believe 11 children Table I. gives the findings as regards growing quite recently. would remember for either one or two years the answer pains :TABLE I.-Semi- Urban Areas. they had given to a question so long ago. If the growing pains were fact the answers are explained. At the end of 1926, after the examination of 650 children, it became clear that the carious teeth were not correlated with growing pains. There were only 19 cases in which there were many carious teeth,. and of these 12 were among the non-rheumatic. The teeth were good as a whole, and greatly superior to 10 years ago. Table II. gives the percentage findings for tonsils :-

Special Articles.

"

TABLE II. It would appear that " growing pains " are at their maximum from 8-10 years (unless the correct age is below this), and that there are more cases in rural than in semi-urban areas. The latter point is confirmatory of figures obtained in 1912,1 when special attention was paid to the frequent existence of pyrexia and the heredity figure of 0-46 was obtained

for " rheumatism." Criticism is sometimes directed against the varying Bearing in mind the liability of rheumatic children numbers found by different examiners to be suffering to tonsillitis, it becomes evident that some of them

growing pains. This condition is so lightly must have been seen at some stage of an attack regarded by both parents and children that no mention (and, in fact, some of them are so marked), and that of it is, as a rule, made, unless the direct question is these would be included in those noted with " enlarged put. Since writing these notes, I have examined 200 tonsils." Hence it does not appear that there is any significant difference between the rheumatic and 1 A Statistical Study of Oral Temperatures in School- the non-rheumatic in regard to the more chronic children. By M. Williams, M.B., B.S., D.P.H., Julia Bell, enlargement of tonsils. M.A., and Karl Pearson, F.R.S.

from

721 The

cardiac

conditions

were

noted

under

of this view it may be mentioned that some cases were in children of rheumatic heredity. Finally, I should like to draw attention to the frequency of epistaxis in rheumatic children. Definite figures cannot be given, but the frequency appears to be more than mere chance. The frequency of mild rheumatism in children suggests that a slow process of immunisation of the race is begun.

support

the

of these

following headings : apex in or outside nipple line ; large visible area of pulsation ; bruit; thudding first

.sound ; accentuated second sound ; thrill.

Table III. gives the findings as to the existence of slight cardiac defects in children who had, or had had, growing pains, at the various ages :TABLE III. ,

TUBERCULOSIS CONFERENCE. OXFORD,

(Dr. Coates’s percentage for children regarded 79-5.)

over

as

LUP]US

were

He asked if any of the audience could answer certain questions, why is lupus more common in females, why is it rare in America, why is it most common in the nose, why may pulmonary tuberculosis lead to laryngeal lupus but not to nasalP As regards treatment he relied on sanatorium principles and the proper use of the galvano-cautery. Finally, he showed several very interesting drawings of the forms of lupus and of the results of treatment. Dr. W. J. O’DoNOVAN (London Hospital) showed a number of interesting slides illustrating a very early nodule, lupus in a mother and child, Dr. Sequeira’s first natural sunlight treatment with a lens and the modern light department at the hospital, numerous cases, some of historic interest, of the results of treatment of facial lupus, lupus in operation scars, certain cases of differential diagnosis, pigmentation, and acid burns. In summarising some of the results of his experience, he emphasised the importance of general treatment which greatly enhances the value of local applications. Local treatment, he said, if drastic enough, will always get rid of lupoid patches, but some agents produce intense scarring. In his experience X ray treatment, if sufficiently thorough to cure the is always followed by carcinoma. He had found that in some cases light treatment had been unsuccessful until salvarsan had been given, even though a most careful inquiry had failed to discover

TABLE V.

different

onlyI

The three series of examinations all tend to show that these grains are a frequent concomitant of early rheumatism. The question that needs elucidation is whether they occur in other conditions, or whether the children who had no other sign of rheumatism at the moment are in reality already infected. In 2

Rheumatic Infection in Childhood, by Dr. Vincent Coates, Brit. Med. Jour., March 26th, 1925 ; and Rheumatic Infection in Childhood, by Dr. V. Coates and Dr. R. E. Thomas, THE LANCET, 1925, ii., 326.

TREATMENT.

.

the epiglottis c-

rheumatic

area

AND ITS

the

healthy-cmmembrane blanches but, theoid Pharyngeal lupus is no always secondary to nasal. Lupus in and larynx differs markedly from tuberculosis in these situations in respect of virulence, for advanced lupoid ulceration of the epiglottis may be almost symptomless, and the same is true to a less extent of lupus in the pharynx. He described three cases to illustrate these points.

examined,

spinal

and the

first session, Sir FARQUHAR ]BUZZARD presiding, a discussion on lupus and its treatment was opened by Sir STCLAIR THOMSON (President of the Tuberculosis Society). He reminded the meeting of certain well-known features of lupus. It is a chronic tuberculous condition, liable to undergo alternate periods of activity and arrest, caused either by bovine or human bacilli, and occurring as a local manifestation, it is more common in females than in males in the proportion of 3 to 1, and commences particularly between the ages of 5 and 14. It is relatively rare in America and Canada, and in Europe is commoner in the northern parts, in cold weather than in warm. and in the poor rather than in the well-to-do. In the upper respiratory tract lupus affects chiefly the nose, the pharynx, and the epiglottis, occasionally the larynx, and rarely the tongue or buccal mucous membrane. Lupus in the nose is often associated with lupus on the cheek, but whether the nasal lesion is always primary is a debatable point. He suggested that the nasal lesion often escapes recognition, perhaps because it may be hidden beneath the blades of the nasal speculum. He said that if adrenalin and cocaine were placed on a suspected place, the At

was

In the remaining 199 children the was examined (Table VI.).

PROVINCIAL

Society

Per-

The second series in which arm and spine gave results as shown in Table V. :-

29TH-31ST.

joint meeting of the Tuberculosis Society of Superintendents of Tuberculosis Institutions was held at the Dunn Laboratory, Oxford, from March 29th to 31st. A

It would appear that the effect on the heart is most common at 12 years, and then begins to pass off. It has long been known that in cases of serious rheumatic disease subcutaneous nodules are sometimes felt. An addition to our knowledge has recently been made by Dr. Vincent Coates and Dr. R. E. Thomas.2 On a visit to Bath by the writer, Dr. Coates very kindly demonstrated tiny nodules and showed how to find them. In the present series an attempt has been made to assess the value of these " nodules." They are to be found most easily over the ulna or over the spine. The nodules under consideration are so small that the word granule better describes them, or perhaps grain would be even more descriptive. On passing the tip of the fingers horizontally across the spine, there is a sensation as if one or more millet seeds were embedded in the subcutaneous tissue and slipped under the finger. In examining the ulnar region, the right hand must be used for the right arm and the left for the left arm. The grains are not as a rule tender. In the first 484 children examined, time only permitted the examination of the arm region. In the next 266 children both arms and spine were investigated, and this series convinced the writer that much less time and trouble is required to find the grains over the spine than those over the ulna. In the first series of 484 children Table IV. records the result :TABLE IV. Grains

MARCH

!

lupus,