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39
At the end of the year, 7,690 children were being supervised, either by school
doctors or at the rheumatism supervisory centres.
Care committee workers visited and made detailed reports on the home conditions
of a large proportion of the children admitted to the rheumatism units during
1937. Altogether 1,448 such reports were received, and in 335 instances revealed
defective housing conditions. These were reported to the borough medical officer
of health in order that further investigations might be made and such remedial
action taken as was possible. The principal defects found were dampness and overcrowding,
but in not a few instances premises were reported to be verminous.
Table 23 sets out in detail the facts which have been briefly summarised above.
The factors associated with the occurrence of juvenile rheumatism all suggest
that it is essentially an infective disease. Its seasonal incidence and social distribution
are both consonant with this view, and its association with tonsillar infections
even tends to implicate a specific organism—the hemolytic streptococcus.
The seasonal prevalence is shown by the accompanying graph (fig. 3), which
was constructed from an analysis of 1,500 cases admitted to the rheumatism units.
The greater proportion of cases occur during the period October to February, and
a definite relationship would seem to exist between the prevalence of the disease
and the amount of sunshine, the mean air temperature and the percentage of atmospheric
humidity. A low mean air temperature, a small amount of sunshine and high
percentage atmospheric humidity when occurring simultaneously, seem to be associated
with a high incidence of juvenile rheumatism, and these are also conditions
which favour the lowering of the resistance of the body to infection.
The distribution of juvenile rheumatism among the various London boroughs
may be gauged by the number of nominations for treatment per 1,000 elementary
school children in each borough. As thus arrived at, the incidence seems to coincide
closely with the density of population and is therefore, in the main, heaviest in
the poorer and more over-crowded boroughs. A comparison of the incidence of
rheumatism in secondary school children with its incidence amongst elementary
school children also suggests that children of less prosperous parents suffer more
frequently. Figures from the secondary schools showed an incidence of rheumatism
equal to approximately .5 per cent. of the secondary school population, whereas for
elementary schools the percentage incidence was about 2.6. Also rheumatism was
found more frequently in "scholarship" children in attendance at secondary schools
than in the fee-paying pupils.
It seems clear that, until more precise knowledge of the infecting agent is available
and it can be attacked directly, the chief efforts, in so far as prevention is concerned,
must take the form of an endeavour to increase the child's resistance to infection.
This can best be accomplished by ensuring a healthy home environment, coupled
with an adequate and well-balanced dietary. It is at present lamentably obvious,
judging from reports received of the home conditions of rheumatic children, that much
still remains to be done in the matter of improved housing conditions, although
great progress has, of course, been made. With regard to an adequate dietary, it
can be confidently expected that the recently established nutrition centres will be
of much indirect assistance in the campaign against juvenile rheumatism.
An analysis of the admissions to and discharges from the rheumatism units
during 1937, is given in tables 24 and 25, respectively.
It is to be noted that approximately 43 per cent. of the children admitted showed
signs of cardiac involvement, but, as has been pointed out in previous reports, in
about 25 per cent. of such cases the carditis subsides, no permanent cardiac damage
being sustained. Even in the group of cases where the heart has been permanently
damaged, the lesion is not necessarily of the severe progressive type.
A special analysis of 1,000 cases admitted to the units revealed the fact
that, when the attack of rheumatism was ushered in by an acute tonsillitis, the
prognosis, so far as the heart was concerned, was particularly grave. In no fewer
Supervision
Home
conditions
Infective
nature of
juvenile
rheumatism
Seasonal
prevalence
Distribution
of juvenile
rheumatism
in London
Prevention
Tonsillitis
and cardiac
damage