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74
From the fact that the number of new Kensington cases seen at the Centre was 151 in
the first year and 145 in the second, it will be seen that the drop in the notifications has been
reflected but little in the attendances of new cases there.
In the Borough of Hammersmith, where there is no provision for the notification of
rheumatism, the Invalid Children's Aid Association were anxious that the rheumatic
children of Hammersmith should be able to take advantage of the Centre established in
Kensington. At the end of the second year, sixty-five cases of rheumatism from Hammersmith
were under our supervision and this number is increasing. It follows that a rheumatism
supervisory centre, backed by an energetic Invalid Children's Aid Association (or a corresponding
organisation) can go a long way without any scheme of compulsory notification. Further,
supported by the local authority and a keen school medical service, it is conceivable that the
assistance of notification would be unnecessary.
Although it is apparent that material can be found for the Centre without notification
and that notification is not providing the bulk of the work, nevertheless it is important to
realise that the work of the Public Health Department cannot be measured in terms of the
notified cases attending the Centre. A close liaison between the staff of the Centre and the
Public Health Department is perhaps the most important factor in the success of the
Rheumatism Scheme.
So far, we have given facts which tell against the general introduction of compulsory
notification : what is there to be said in its favour ?
Though notification provides but a small proportion of the cases under supervision at
the Centre, we have found that there are cases of rheumatism brought to our notice by its
agency of whose existence we would otherwise be ignorant. It is true that in order to be
notified they must have come under medical care on at least one occasion, but unfortunately
private medical practice in this country, even at its best, has but little opportunity to concern
itself with the supervision of persons not actually ill. There is enormous scope for preventive
work and for the supervision of the healthy in private practice, but as yet medical evolution
has not accomplished any considerable development along these lines. The supervision of
rheumatic children, between attacks, nearly always falls to the lot of hospital outpatient
departments and rheumatism clinics. The larger the number of cases notified to the Medical
Officer of Health by private practitioners the greater will be the benefits of notification in
revealing those rheumatic children who, after recovery from an acute attack, are not kept
under their doctor's supervision.
The time has come to answer a pertinent question : could a Rheumatism Scheme such
as the Kensington one be efficiently organised and successfully conducted without compulsory
notification ?
Basing our view on the experience of two years' work and on the figures which have been
presented, we have come to the conclusion that the Rheumatism Supervisory Centre could
be kept busy without any scheme of compulsory notification ; and the truth of this is apparent
when we recall the numbers of rheumatic children from the Borough of Hammersmith seeking
advice and supervision at the Kensington Centre. To this conclusion must be added our opinion
that if the Rheumatism Supervisory Centre is to be successful it must have enthusiastic support
from such recognised public bodies as the local authority and the education authority.
As an alternative to notification there is another solution which we put forward for the
consideration of authorities concerned with the problem of juvenile rheumatism. It is
agreed that in this country juvenile rheumatism occurs for the most part (a) in children of
school age and (b) in the social strata below that of the well-to-do. Juvenile rheumatism
is a rare disease in the private practice of doctors in good class residential areas, in
private schools, and in the public schools of the well-to-do. In the adult, it is comparatively
uncommon except in cases when it originates in childhood. From these considerations, it
follows that the school medical service should be in a position to deal very effectively
with the problem of the control of rheumatism, though we are not convinced that they
can do so with their present organisation. The setting up of rheumatism supervisory centres
is essential, and we believe that they should be fed chiefly by the school medical service,
other bodies being encouraged to refer children to the Centres even though they are
below school age. We would like to see rheumatism centres in number sufficient to cope
with the disease in each area, set up in close association with the existing hospitals, and staffed
by physicians of general experience.
While taking this view, we also wish to make clear that the notification of juvenile
rheumatism has been of value outside the sphere of the supervision and treatment of rheumatic
children. Environmental research can be greatly aided by a well-conducted scheme of notification,
and we believe that it would be advantageous to continue in existence three or four
municipal schemes of notification in the London area in order that these environmental
investigations may be allowed to mature.