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Progress has been made in regard to the provision of modern cardiac diagnostic
apparatus at the rheumatism units, and a considerable amount of patient investigation
in connection with the treatment, diagnosis and pathology of the disease is
being carried out. So far as treatment is concerned, no spectacular advance has yet
been made and rest under good hygienic conditions still remains the mainstay of treatment.
The period necessary naturally varies, but six months may be regarded as a
fair average. Absolute recumbency during the whole period is not implied; to quote
Dr. Gray Hill, who for many years has supervised the rheumatic unit at Queen Mary's
Hospital "a prolonged period of forced recumbency proves a strain on the patient and
rest and strain are diametrically opposed; rest must be natural not forced." Accordingly
at the rheumatism units the regime is one of gradually increasing physical activity
combined with suitably planned education. The results are that the children
remain happy and occupied during their stay in hospital—an important factor of
successful treatment—and are better able to hold their own educationally on returning
to a day school after discharge from a hospital school.
At the end of the year, 7,792 rheumatic children were registered as being under
supervision. Of these 5,160 were in attendance at rheumatism supervisory centres,
and 2,632 were under the supervision of the school doctors. These figures are substantially
the same as those for the preceding year. Much administrative work in
this connection devolves on the school care committees, who also furnish reports on
the home surroundings of the children. Their work cannot be valued too highly,
more especially in the matter of the notification of defective conditions in the homes.
The number of rheumatism supervisory centres remains still at 20, but an
additional centre at Clapham will be available in July, 1939. With the opening of
this centre every area in London will be provided for. The centre at Reginald
Square, Deptford, has been moved to more convenient premises at Creek Road,
Greenwich, and this will enable the work there to be carried out in close co-operation
with the Greenwich medical officer of health.
In view of the widespread belief that attacks of chorea are related either to
mental or physical " shock " and perhaps to the strain of school work, it was thought
that it might be instructive to obtain, if possible, definite figures. Accordingly, 296
cases were analysed with this object in view, and it was found that a clear history of
fright or physical injury or surgical operation immediately preceding the attack was
present in just over 8 per cent, of the cases. It would seem that such factors have a
definite influence in an appreciable number of cases. This perhaps should be borne in
mind in considering the desirability of operations such as tonsillectomy. In so far
as school work is concerned there is no convincing evidence to support the view that
it is an important predisposing cause of chorea. Of the 296 cases analysed (all
children attending elementary schools), in only four was the attack attributed to this
cause. In secondary school children the proportion was somewhat higher, but the
small total number of cases found amongst these children suggested that the incidence
of chorea in secondary school children was particularly low. Nevertheless it is of
interest to note that, in children suffering from recurring attacks of chorea, a transfer
to a school for physically defective children very frequently results in the cessation of
the attacks. Occasionally, after a period, these children have been retransferred to an
elementary school and an immediate relapse has occurred. On the other hand, a
steady fall of the prevalence of chorea occurs after the age of nine, and this would
seem to negative the suggestion that preparation for examinations plays a considerable
part in its occurrence. It is just at this age that the competition for scholarships
makes its appearance, and, if preparation for examinations played any significant
part, one would expect a rise in the incidence of chorea between the ages of nine
and twelve. Probably the important point in the relationship of school work to the
incidence of chorea is the presence of an inborn bias towards nervous instability.
Supervision
Precipitating
causes of
chorea