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36
to October but this lowering of incidence does not appear among girls. While an
examination of these figures may not be of much scientific value they are of considerable
interest in administration. Pressure on the beds at the disposal of the
scheme has always been heavy even during what are regarded as the non-rheumatic
months of the year.
Comparative
incidence of
rheumatism
in the sexes.
The figures for the hospital admissions during the period in which the
rheumatism scheme has been in operation do not provide any information of value
on the comparative incidence of rheumatism in the sexes, for more beds have always
been available for girls than for boys. The same criticism applies to the numbers of
boys and girls in the nominations received, for, because of the known shortage of
boys' beds, the agencies have hesitated to nominate boys. Some idea of the comparative
incidence may be obtained from the reports of the rheumatism supervisory
centres ; of 1,213 children definitely diagnosed to be rheumatic there were 482 boys
and 731 girls. A like proportion appears in the figures on the rheumatism register
for 16,911 children, there being 6,598 boys and 10,313 girls. The ratio of three
rheumatic girls to two rheumatic boys is also shown for a number of years in the
figures for children out of school for lengthy periods. The importance of bearing this
proportion in mind in allotting future accommodation is readily seen when it is
remembered that in the past one of the great administrative difficulties has been
that a much smaller proportion of boys' beds has been provided than was necessary
for the satisfactory working of the scheme.
Age of onset.
During the year an examination has been made of the statistics which have been
accumulating since the inception of the rheumatism scheme for the purpose of
obtaining some idea of the age at which first attacks of rheumatism (including
chorea) make their appearance. The result shows that rheumatism reveals itself
as a disease which usually begins during the early school life of the child. Examining
the history of 1,700 rheumatic children it is found that 685 (40 per cent.) first attacks
occurred in the 6-8 age period, and 498 (29 per cent.) in the 7-8-year-old period.
A curve plotted to demonstrate the incidence of first attacks at the different ages
shows a sharp rise from the age of five to a maximum at eight and then a fall to a
level below that at age six and this level is maintained until the age of thirteen, whence
the incidence falls below the level for the four-year-old. In 500 first attacks of rheumatic
fever the chief incidence was within the same three years, 6-8 ; 200 (40 per
cent.) of the attacks arise in this period with a maximum at six years of age, while in
386 cases of chorea 172 (44 per cent.) of first attacks fell within the 6-8 period with
a maximum at seven. A family history of rheumatism is more frequently met with
in children whose initial attack of rheumatism occurred before eight years of age,
but faulty home environment was recorded more often in children whose rheumatism
began after this age. Heredity may influence the age at which rheumatism makes
its appearance.

Rheumatism
and heart
disease.
Two sets of statistics are available which throw some light on the proportion of
rheumatic children in whom the heart is attacked. The first of these is obtained from
the discharge reports of 1,325 children treated at Carshalton or Brentwood: 728
(55 per cent.) of these children had heart disease of whom 346 (26 per cent, of the total
number) had established valvular disease. These children were suffering from
rheumatism of a severe nature. The returns from the rheumatism supervisory
centres, on the other hand, supply a second set of figures relating to children who are
affected by the milder manifestations of the disease in addition to others who have
been more severely attacked. Of 1,529 children diagnosed as definitely rheumatic,
the heart was affected in 630 (41 per cent.) and valvular disease of the heart was
present in 209 (14 per cent.).