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but 55 were subsequently withdrawn, reducing the total to 2,342. Happily this
increased number need not be regarded as indicating a proportionate increase
in rheumatic disease in children, but is chiefly due to the fact that 1936 was the
first complete year during which the scheme was made available for rheumatic children
in the Council's general hospitals. To compare the 1936 figures with those of the
previous three years is therefore misleading, unless the number of nominations
received from Council hospitals is first deducted. When this is done a total of 1,674
nominations received from sources other than Council hospitals remains, and this
shows a slight decrease on the average yearly number (approximately 1,700) received
during 1933, 1934 and 1935. The number of applications for treatment under the
scheme cannot, of course, be regarded as a measure of the incidence of rheumatism
in children of school age, but it supplies an index of the fluctuations in prevalence
from year to year, and as such indicates that, even allowing for the decrease of the
school population during the last few years, no sensible increase of rheumatic disease
is occurring. Nor, unfortunately, is it possible to point to a decrease, and, since
at the present time the immediate causation of juvenile rheumatism and the factors
conducive to its occurrence are more matters of speculation than ascertained fact,
no advance in the direction of prevention seems at present possible. It is clearly
of the utmost importance that skilled research workers in bacteriology, biochemistry
and cardiology should concentrate on the problem. The absence of definite knowledge
regarding the causation of the disease inevitably reflects itself on the question
of treatment. The real danger of rheumatic disease in childhood is of course the
danger of cardiac involvement with the possibility of permanent cardiac crippling.
All statistical evidence tends to show that prolonged rest in the early stages of the
disease reduces this risk. Herein lies the value of the Council's rheumatism scheme.
But juvenile rheumatism frequently takes the form of an insidious carditis
which gives rise to few or no symptoms in its early stages. This partly accounts for
the fact that evidence of cardiac involvement was already present in 37.7 per cent,
of the 2,039 children admitted to the rheumatism units in 1936. In a certain
proportion of these cases of carditis, where the children had been fortunate enough
to be admitted at the very onset of the disease, its progress was arrested and no
permanent cardiac damage resulted, but in a much larger proportion of cases cardiac
valvular disease was definitely established, and, of the 1,900 discharges from the units
in 1936, 21 per cent, were, owing to this cause, regarded as unsuitable for normal
school life or unfitted to undertake without risk any but the lightest employment.
Except for a short period in the early part of the year, when part of the Southern
hospital convalescent unit had to be used to provide additional accommodation for
children suffering from measles, the number of beds (910) allocated proved to be
adequate, and no delay occurred in the admission of children to the units. The
number of children under supervision at the rheumatism supervisory centres has
remained approximately stationary during the last three years. On the other hand,
there has been a distinct tendency for the number under supervision by the school
doctors to increase. The number this year (2,596) shows an increase of about 800
over the number thus supervised in 1934. Much help has again been given by the
children's care organisation in connection with the work of the rheumatism scheme.
In addition to making many special enquiries regarding children out of school owing
to rheumatism, care committee visitors have made reports on the home conditions
of all children admitted to the units. Amongst these, 442 reports showed that the
home conditions were unsatisfactory and appropriate action was taken with a view
to their amelioration.