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There are many cases which cannot be definitely labelled acute rheumatism, and therefore cannot be notified,
which should be under supervision. These include children who have pains or arthritis not accompanied by a
rise of temperature and children who have had one or more definite attacks of rheumatism, in whom the disease
is now quiescent, but in whom there is a danger of a recurrence.
It has been stated that although there is thought to be a striking difference between the incidence of rheumatism
among the well-to-do and the hospital class, there is no statistical evidence about the former. Notification
in a borough such as Kensington, which embraces well-to-do districts as well as very poor, should afford
such evidence.
It was pointed out in an earlier report that environmental research into the etiology of rheumatism can be
greatly assisted by a well conducted scheme of notification with its resulting close liason between the staff of the
centre and of the Public Health Department; and it will be advantageous to continue this Kensington Scheme in
order that many important environmental investigations may be allowed to mature.
Notification is of value to the Borough of Kensington in the fight against rheumatism, apart from its direct
value in sending cases to the Supervisory Centre in their early stages. In the year under discussion there were
95 notified cases, 36 of these cases attended the centres as new cases. This was a higher proportion than in the
previous year when only 33 out of a total of 105 attended the centre.
It must be observed, however, that a large proportion of these notified cases are not the direct responsibility
of the medical officer at the centre. Some are able to afford to be treated at home by their own private practitioners,
and others are immediately admitted into a hospital owing to the fact that the urgency of their symptoms
makes any delay inadvisable. Nevertheless, these cases are not neglected by the Centre. After their medical
practitioner or the hospital has discharged them they are visited by the health visitors and by the Honorary
Secretary of the Centre in conjunction with the Invalid Children's Aid Association. It may be found that supervision
is being maintained by the practitioner who was in charge of the case during its active state, in which event
this satisfactory condition of affairs is reported. Often, however, the financial status of the parents makes this
impossible. These cases are advised to attend the supervisory clinic, and are referred back to the practitioner
if unsatisfactory symptoms recur. Cases discharged from hospital are treated in a similar manner.
INVESTIGATIONS CONCERNING ETIOLOGY.
Contact Cases.
In view of the statement in the Medical Research Council's Report* on Acute Rheumatism in children that
“there is at least a ground for suspecting that rheumatism can be conveyed in some way from person to person,
and that, as might be expected, closeness of contact favours its transmission,” investigations are being made
into the sleeping accommodation of rheumatic children.
An analysis of 78 cases:—
Group 1. Child sleeping in room in which no other children sleep 19 or 24.4 per cent.
Group 2. Child sharing room or bed with another child or children 59 or 75.6 per cent.
(a) Child in separate bed 14 or 17.9 per cent.
(b) Child sharing bed with 1 to 4 other children 45 or 57.7 per cent.
In Group 1, therefore, the question of the spread of rheumatic infection by close contact during sleeping
hours between one child and another does not arise.
In Group 2 there is no evidence that sleeping in the same bed as compared with sleeping in the same room
gives a higher incidence of contact cases.
An analysis of Group 2.
(a) In 14 rheumatic cases the child attending the clinic sleeps in a single bed, but one or more other children
occupy the same room.
In 11 cases or 78•5 per cent, the other child or children show no evidence of rheumatism.
In 3 cases or 21•5 per cent, there is evidence of rheumatism in the children occupying the same room.
(b) In 45 rheumatic cases attending the clinic the child shares his or her bed with another child or other
children.
In 37 cases or 82 per cent, the other child or children show no evidence of juvenile rheumatism.
In 8 cases or 18 per cent, there is evidence of rheumatism in the children occupying the same bed.
Thus in Group 2a the possible contact cases are 21.5 per cent., and in Group 2b, where the chance of infection
is greater the possible contact cases are 18 per cent.
The number of cases analysed is small and no definite conclusion can be drawn from them. Up to the
present there is no evidence that the very close contact of sleeping in the same bed as opposed to the less close
contact of sleeping in the same room, but in separate beds, has caused a greater spread of rheumatism.
Taking Group 2 as a whole, it appears that in 19•25 per cent, there was more than one case of rheumatism
in the family, but it is not possible to draw any conclusion from this observation alone, as so many other factors
such as heredity, clothing, feeding and lack of maternal care may be concerned.
Environmental Factors.
Careful comparisons have been made between a map which shows the distribution in the Borough of notified
rheumatic cases during the three years 1927-1930, and maps showing:—
(1) Damp flood areas.
(2) Rat-infested areas.
(3) Various soils.
(4) Poverty.
In the first three cases no definite connection can be shown.
* Medical Research Council — Special Report — Series No. 114.