Chronic polyarthritis in childhood is a disease of considerable frequency.In the medical wards of the Hospital for Sick Children, Great Ormond Street, sixty-nine cases have been treated since the war. There are additional outpatient cases which are not admitted to the wards and it is estimated that a new case may be seen at the hospital every twelve weeks.In the wards the clinical picture of the acute phase is familiar, but apart from certain cases with early recovery the end results are seldom seen, so prolonged is the course of the disease. The institutions for chronic rheumatoid arthritis collect the most severely crippled but these form a minority. The fairest assessment of prognosis is attained by a follow-up enquiry of a consecutive hospital series and for this purpose the post-war cases have been taken. The cases under reviewThe series of sixty-nine is depicted in fig. 1 where the cases are arranged according to the age of onset. Two cases are seen to have begun in the first year of life, fourteen cases in the third year with a maximum incidence in the pre-school period between two and five years. The sex incidence is also indicated. Sixty per cent. of the patients were girls.Follow-up results. The results of the follow-up enquiry are shown in fig. 2. Enquiries were successful in forty-nine cases (twenty cases were untraced). Of these, twelve are known to have died, eighteen are still active and nineteen are quiescent. The criteria of quiescence have been an absence of joint pain and tenderness for a period of not less than two years, and a blood sedimentation rate within normal limits. In no instance have symptoms recurred after a quiescent period of eighteen months.The fatal cases. A recognition of the considerable mortality was the first finding of importance ( fig. 2). Twelve of the patients followed have died and in each case before reaching adult age. Each fatal case had first developed the condition under five years of age and with one exception each one had died within three years of the onset. The disease is thus most dangerous in the acute stages in the young children. Figure 1 shows that forty-two of the cases developeid symptoms in the first five years of life. Of these, twelve are dead-a mortality of nearly thirty per cent. at this period. The disease is thus most fatal in the years when it is most frequent.
A knowledge of birth order can be contributory to the evaluation of hereditary and environmental factors in disease. There is, however, no agreement as to whether a characteristic birth order pattern exists in epilepsy. Thus Brain (1956) and Lennox (1960) (1950) and Orr and Risch (1953) by their use of sibs of the reference epileptics as controls but here bias was possible to the extent that parents who have had an epileptic child might limit family size afterwards, causing such an epileptic to hold a relatively late birth order position in the family. METHOD OF ENQUIRYWith all these considerations in mind, the following method of enquiry was adopted. From the hospital records all patients diagnosed as epileptics were collected and follow-up enquiries on them conducted during 1957 and 1961. There were then selected for further investigation those who were either first born with a second born sib control, or second born with a first born sib control, and had suffered 10 or more 'convulsion days', a 'convulsion day' being defined as any day in which the patient had one or more convulsions. The first stipulation secured the advantages of Alstro.n's enquiry but placed bias on the epileptics of the enquiry series being second rather than first born, and the second stipulation excluded convulsions which were exclusively febrile and also slight, infrequent convulsions, so minimizing bias which might arise from the possible tendency of parents to be more worried by illnesses in first children, that is, the standard of severity adopted was such that the affected children were likely to have been referred for hospital investigation whatever their birth order. It remained to arrange that the sibs of each pair be observed for 59
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