Rheumatic infection in childhood: Influence of type of onset and calendar year of onset

Abstract

The course of 583 children who suffered from rheumatic infection which originated during the years 1922 to 1936 has been described. Ninety-four and eight-tenths per cent of these children have been followed for a minimum period of three years and an average period of 9.6 years since the primary manifestation. At the end of this time, 64.2 per cent presented signs of valvular heart disease and 21.7 per cent had died of rheumatic infection. An additional 3.5 per cent had died of bacterial endocarditis or other infection associated with active rheumatism. The course of the disease was modified by the type of onset; acute carditis presented the most ominous prognosis and chorea the most favorable. Children with a diagnosis of potential heart disease at the onset frequently tended to retain their freedom from signs of heart disease, in spite of recurrences. A trend toward a decrease in the severity of rheumatic infection has been noted during the period of observation; this has been manifest especially among patients whose primary symptoms were arthritic. This improvement in the course of the disease cannot be ascribed to racial variation, relative changes in type of onset, progressive decline in recurrences, or a modification of the policy of the hospital in regard to admissions. Although it is part of a downward trend in mortality from heart disease among young people throughout the United States registration areas, the decrease in mortality at the Children's Hospital has been greater than that in Pennsylvania as a whole. Within recent years an attempt has been made at the Children's Hospital to concentrate attention on the child with the first manifestation of rheumatism, however mild. Such children have been kept at rest in bed and their activity restricted for longer periods of time. Whether such intensive supervision of the child with early signs of the disease has accelerated the natural trend to improvement is a subject for speculation. A recently adopted, conservative attitude toward tonsillectomy seems at least to have had no unfavorable influence. The experience at the Children's Hospital with patients who were transferred to a convalescent home would seem to indicate that, although such convalescent care may serve a valuable purpose in ensuring stabilization of the infection in the child who has recovered from an acute attack, it is no substitute for absolute bed rest for the child with any degree of active infection. In spite of the seeming decline in severity, rheumatic infection still remains the most serious disease which attacks children past the age of infancy. 5,6 In the most favorable period of the present study (1932–1936), almost 7 per cent of the rheumatic children had died by the end of the first year, and 10 per cent by the end of the third year, at which time 50 per cent of the group had presented obvious signs of rheumatic heart disease.