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"(4) The registration, following up in their own homes, and arrangement of
after-care of cases notified. It is important to keep an accurate register. With
regard to home circumstances, it is well known how difficult even careful parents
find it adequately to carry out medical instructions. Care Committee workers
visit the homes, make reports, and impress on the parents the importance of complete
rest in cardiac cases. Accurate information of home circumstances, in many cases
supplemented by personal observation, is thus obtained, and with more material
it is hoped to use this in a review of home conditions and the occurrence of rheumatism
in the young. One of the great difficulties, and one of the most important factors, is
the arrangement of prolonged convalescence and after-care when the acute attack has
subsided. Arrangements by which acute cases can be admitted into the hospitals
at High Wood or Carshalton exist, and owing to cordial relationship of the centre,
the organiser with the I.C.A.A., and kindred organisations, children can be rapidly
removed to the above hospitals with their special rheumatic beds, or other convalescent
homes. This arrangement meets the difficulty which occasionally occurs
when a child, owing to lack of beds, is unable to have a sufficiently long stay
in hospital, and when home conditions may not be such as render it desirable
for him to be sent home. The difficulty of securing adequate rest at home has
been brought home very forcibly—choreic children often sharing beds with one or
two other adults or children, and it is a moot point in some cases whether owing to
this fact, and slack discipline at home, the children are not quieter in school.
"Opportunities occur for research in all aspects of rheumatism. The material
is abundant and concentrated. Lectures have been arranged which have been
well attended. School doctors are always welcome to see these cases. In the
centre at the Royal Waterloo Hospital every effort is being made to advance the
research side. A small team of experienced workers has been collected, and it is
hoped to have a unit of five beds for in-patient investigation of rheumatic fever.
"During the year an inspection has been made of all the cardiac cases in two
P.D. schools. The importance of sending rheumatic cases there for a period of six
months after discharge from hospital was apparent on many occasions. Many
cases there were reviewed and an attempt is being made to arrive at some method
of classification of these heart cases. An investigation is also being made with
the assistance of the care committee into the after-history of cases leaving these
schools. Parents are interviewed at the schools and the importance of keeping
up the treatment is stressed. In cases where no treatment is being given, this is
arranged. In a review of cases in this way, it has been possible to decertify some
now well, and a study is being made of the difference between children in P.D.
schools and others.
"With regard to the clinical method of estimating cardiac efficiency the aim
is to obtain if possible, (i.) an objective test whereby an observer can estimate
changes noted by a former observer, (ii.) a method of classification of hearts, and
(iii.) a numerical method of denoting progress or otherwise in heart cases.
"The study of large numbers of notes shows clearly the difficulty of tracing
the opinion and history of the heart held by a previous observer owing to the
vague and varied nomenclature used. In these tests definite figures are obtained.
The work, which is based in part on that of Schneider and Blumer, consists only
of simple estimations which can be easily carried out in an inspection at a
school. The factors considered are (i.) the reclining pulse rate, (ii.) the standing
pulse rate, (iii.) the increase in these two factors, (iv.) the pulse rate after exercise,
(v.) the time for the pulse to return to normal, (vi.) the difference in the
reclining and standing blood pressures. The exercise has been standardised
to touching the toes with the hands twenty times. The first five factors can advantageously
be ascertained by the school nurse who has entered them in a book, in
some cases, before inspection. The child is used to the nurse and the factor of