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126
Geographical
distribution.
The incidence of rheumatism is not uniform either in the country or in the
London area itself. It is commonly held that rheumatism is apt to cling to low-lying
clay soils. Dr. Jean Shrubsall, working in the London School Medical Service,
found, in 1912, that children suffering from rheumatic heart disease were not uniformly
distributed over the county area, but there was a definite aggregation of cases along
the lines of the alluvial valleys marking the ancient courses of rivers, such as the
Hole Bourne or Fleet, the West Bourne, the Bridge Creek (Notting Dale), the Wandle
and the Effra. The inquiry has been repeated by Dr. F. C. Shrubsall in order to
ascertain whether these observations made in 1912 are confirmed in the figures for
1925, and the result is shown in the diagram on page 125.
For purposes of comparison cases of encephalitis lethargica, during 1924 and
1925, are placed upon the map appearing below that relating to heart disease. Tn
the case of encephalitis the distribution of the cases appears to be governed in the
main bv densitv of population.

The unequal distribution of cases has a bearing upon the question of coordination
of effort between the various institutions and authorities dealing with the
problem.
Prevention.
The widespread incidence, the serious complications, the permanent injury,
especially to the heart, the reduction in expectation of life of sufferers and the
diminished capacity for work make it especially important, in the interests of the
public health, that facilities should exist for the early and adequate treatment of all
cases of rheumatic nature in childhood.
In the present stage of knowledge, it is not possible to suggest specific steps
whereby attacks of rheumatism can be prevented. Attention to the health of illnourished,
debilitated and anaemic children is being carried out by the school care
committees.
The entry of the infection is generally believed to be by the route of the tonsils,
and Sir George Newman has suggested that the diminution of the more severe cases
of rheumatism in childhood has been associated with the greater attention to nose
and throat ailments which the School Medical Service has secured. In addition to
this factor, improvement in the housing conditions and in home care of children
must have a considerable effect in reducing the incidence of the disease.
At the present time the most hopeful measures appear to be those which may
be taken to mitigate the serious sequelae of rheumatism, and consist in the extension
of special facilities for convalescent treatment. All authorities are agreed that
prevention of cardiac involvement and cure of the early heart disease are obtained
most certainly in cases of rheumatism by prolonged rest in bed under supervision,
followed by graduated activity, such as could only be secured in special convalescent
-homes. The experiment of sending rheumatic children to ordinary convalescent
homes has not proved successful.