The Outlook for the Rheumatic Child

THE problem of the future of the rheumatic child depends on various factors, the value of many of which is difficult to assess. In the first place, the presence of the rheumatic toxin is frequently difficult to prove: as Mackiel has said, "Rheumatism is a chronic and often progressive disease characterized by alternating periods of activity and quiescence, and the age at onset plays a dominant r6le in determining its clinical phenomena": in the young child the early clinical phenomena may be at first so ephemeral that the presence of established carditis may be the first positive sign of its presence; there is, as yet, no serological test comparable with the Wassermann or tuberculin tests, and therefore the diagnosis rests on a purely clinical basis, as syphilis formerly did, but with, in many cases, less florid stigmata. It is interesting in this regard to note that, having educated the public to regard growing pains as rheumatic, there is a tendency amongst paediatricians2 to deny that growing pains are ever rheumatic. Personally I do not agree with this modern view. Secondly, it is difficult to know whether the toxmmia is inactive. Smith and Sutton3 suggest the following criteria of probable inactivity (1) That the child is symptomless. (2) That the temperature has been continuously normal for at least two weeks. (3) That the leucocyte count is normal. (4) That the pulse-rate is "fairly stable." (5) That the weight is increasing. (6) That the vital capacity is increasing. Possibly the most informative pulse-rate is that obtained while the patient is asleep. In my experience, considerable patience is needed to obtain reliable spirometric readings of vital capacity in children.