London's Pulse: Medical Officer of Health reports 1848-1972

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London County Council 1934

[Report of the Medical Officer of Health for London County Council]

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34
with 244); and, as these are the more severe and acute cases, it is clear that no
notable decrease in the incidence of rheumatism or chorea can be visualised at
present.
During the first half of the year it became increasingly evident that, if the
growth of an abnormally long waiting list were to be avoided, with a consequent
delay in admitting cases, a more rigorous sifting of the nominations would have
to prevail. In the very mild or doubtful cases, therefore, local supervision at a
supervisory centre or out-patient department was advised, and numbers of slightly
more definite cases were dealt with by means of supervised convalescence. For
this purpose greater use was made of the Lower Southern hospital at Dartford.
As a result of these measures it has again become possible to admit the majority of
cases within ten days of nomination, and the more urgent cases immediately. The
system of having the children who are nominated for treatment under the scheme
examined by " referees " specially selected for this work is clearly of the utmost
value in preventing undue congestion of the rheumatism units with unsuitable
cases.
Of the 1,571 nominations for institutional treatment received, the voluntary
hospitals were responsible for more than half (804), the majority of the rest being
sent in by school doctors (320) and supervisory centres (313). A certain number
of parents refuse to accept treatment when they understand that it involves the
child being away from home for six months or more. As many of the children do
not appear very obviously ill, this attitude on the part of the parents is perhaps
understandable, but even so the total number of refusals during the year was
relatively small, being 111 only.
The figures showing the conditions present in the children admitted to the
rheumatism units and convalescent homes (table 12) show the usual preponderance
of girls as sufferers from rheumatic infections (662 girls ; 434 boys). The percentage
of those cases in which the heart had become implicated is almost exactly the same
in the two sexes (boys 38, girls 37), indicating that, although girls are
obviously more susceptible to the rheumatic infection than boys, there is no
sensible difference in the severity of the type of attack experienced. That evidence
is present of the heart being affected in nearly 40 per cent. of the cases admitted
is certainly disquieting, but happily in many cases the degree of involvement is
slight; and, what is still more gratifying, an analysis of 1,094 unselected cases
discharged during 1934 revealed the fact that, of the 600 who showed signs of cardiac
involvement on admission, 149 (i.e. nearly 25 per cent.) had no signs of cardiac
disease on discharge. Even allowing for the possibilities of observational variations,
these figures afford striking evidence of the value of prolonged rest in cases of
rheumatic carditis. Furthermore, of the 490 cases without cardiac complication
on admission, only ten developed signs of cardiac involvement whilst in hospital,
and seven of these were of a very mild or even doubtful type. The case of those
who insist that the prevention of cardiac crippling depends on the early and prolonged
treatment of juvenile rheumatism becomes even stronger as information
about this obscure disease accumulates. Herein lies the value of the present
rheumatism scheme. Rheumatism cannot be prevented until more has been discovered
of its aetiology, but there is good hope that its devastating effects on the
heart can be minimised or avoided altogether by early and prolonged rest.
Unfortunately many of the cases have well-established heart disease before
they come under treatment, and in table 13, showing the recommendations made
with regard to education in the 1,226 cases discharged from Carshalton, High Wood
and the Downs hospitals in 1934, it will be seen that 198 (i.e., 16 per cent.) were
found fit to attend a school for the physically defective only, and 28 were unfit
for any form of education. Of the 128 who were over school age on discharge, a
proportion also were only fit for the very lightest work on account of cardiac disease.
In considering the incidence of rheumatism and chorea separately it is difficult
to come to any definite conclusions. The diseases are closely related, and, in a
large majority of mild cases of chorea, careful enquiry elicits the presence of