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Acute rheumatism in children—The Bristol scheme
37¢
PUBLIC
impress its seriousness and the need for action. In his introduction to the report, Sir George Newman also insists that a serious view should be taken. Heart disease has a preeminence amongst " the captains of the men of Death " : its relative, if not its real, mortality is steadily increasing; half of its weight may fall upon aged, worn out and degenerated, hearts, but there r e m a i n s - t h e other half which fails upon childhood, on youth, on the young adult and those in early middle age whose hearts have been attacked as a result of an infective process, more particularly that of acute rheumatic fever, to which probably not less than 40 per cent of all deaths from heart disease may be ascribed. That the process is an infective one the report accepts, though it is admitted that there is as yet nothing definite in the shape of proof. W i t h o u t knowledge with regard to the actual causative factor it has been found possible to take preventive action, and with some success, in other diseases by levelling an attack against the conditions predisposing to infection. In acute rheumatism the same course should be open even though, as it unfortunately happens, many if not most of the factors appear to be social rather than what may be called sanitary. Unfortunate, because evils and defects in relation to s u r r o u n d i n g s are matters easily dealt with in comparison with malnutrition and maternal neglect. For the remedy or removal of the causes of bad housing conditions, of dampness even, if other measures t~ail, compulsion is available. Not so,however, in regard to the removal of tonsils, an operation for which, it is interesting to note, the report claims high prophylactic value, provided it is performed sufficiently early. Given education it might be found easier to ensure a more effective attack upon the predisposing causes, and education is set down in several places as one of the chief preventive weapons for use, not only against the infection but against the heart sequelze and the effects they may produce if neglected. The burden of the song of prevention is ever--begin with the beginnings. And if the beginnings were easy to find a n d the beginning easily made, the results in cases in which they have been possible show how hopeful the position might be. The difficulty lies in the puzzle of symptoms that the acute rheumatic processes and the cardiac infections present. Definitely members of the group of " silent sicknesses,!' even the skilled diagnostician may fail to
HEALTH.
SEre'EMBER,
detect them; save on the most searching investigatio.n. And only too. seldom is it upon the skilled diagnostician that reliance for a decision is placed. More usually it is to the mother, ignorant of necessity, and often, as has been shown, neglectful, that the victim and those who might help him must look for the signal. The difficulties associated to some extent may be met by talking and warning and by warning and talking again and again, and by advising repeated and periodic medical examinations. In these days in this country, up till the end of the school days at any rate, this is not too difficult to arrange, and what the report says in this regard is for the school medical Officer and others to note. He and they will note al~so what is said as to the necessities for the infected, and the results that h a v e been obtained from rest with medical and nursing care and supervision. T h e y will note that the provision for affording this treatment to all that require it is inadequate, and will lose no opportunity o f bringing home to those who can make good the deficiency what the investigation at St. Thomas's Hospital has shown : that " for every child fortunate enough to be admitted as an in-patient, there are two, three or even four children who need in-patient treatment and who do not get it." W h a t is true of St. Thomas's is true of the country as a whole : the proof that it is true is here in this report, that provides also p r o o f that there is need for action, and that the time for action is now. -g-
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Acute Rheumatism in Chil&en--The Bristol Scheme. S T the areas in which active A MstepsO N Ghave been taken in the direction of dealing with the problem of acute rhemnatism and its sequelae in children must now be included Bristol. Here there has been placed on a firm basis what f o r several years past has been an informal understanding between the school medical officer and certain members of the voluntary hospital staffs in the city, by which elementary school children with cardiac disease have been submitted to the latter for expert examination and report. The Bristol Education Committee have secured from the Bristol General Hospital permission to send children with actual or potential cardiac disease to a clinic to be held weekly under the direction of one of the honorary phys!cians to the hospital. Moreover, in the neighbouring counties of
192r.
PUBLIC
Gloucestershire, Somersetshire and Wiltshire, a similar plan is to be inaugurated. Physicians of experience in cardiac disease have agreed to undertake visits to centres at which groups of children will be assembled for examination and repo.rt. Arrangements have also been made whereby reports on cases of rheumatic heart disease in childhood discovered in the practices of private doctors, as well as in school clinics, may be collected and the conditions under which the disease arose investigated by the county medical officers in collaboration with t h e University of Bristol Institute of Cardiac Research, which is housed at the Bristol General Hospital. Finally, as an inevitable development of this assembling and scrutiny of cardio-rheumatic children, the new hospital school about to. be built at Winford, on the outskirt.s of Bristol, and facing the Mendip Hills, is to include provision for the treatment of rheumatic heart disease in those children who need prolonged c0nrses of institutional care. The scheme for the entire area has received the sanction of the Board of Education, and is believed to be the most extensive of its type in E n g l a n d at the present time.
Health in the Factory. during the last four or five, or A Tit intervals may be more years, the country has been s h a k e n by the tidings that presently there would be passed into law a Factory Act that, by excluding local health authorities and their officers from factories and workshops, would ensure that these places were palaces of health and fit to labour in. No later than the beginning of July of this year, the H o m e Secretary, in the course of his Presidential Address at the Congress of the Royal Sanitary Institute, after a number of neat compliments to sanitary inspectors and medical officers of health--in that order--and a description of the manicure rooms and other wonderful things he had seen in certain establishments, declared his intention to delay no further, but to place on the Statute Book a piece of factory legislation that he himself felt to be long overdue. Now there has just been issued the annual report of the Chief Inspector of Factories and Workshops for the year 1926, which gives rise to no feeling but one of wonder that it should have been necessary for anyone to talk so much of the need for a new measure, to arouse alarm in the minds of all factory
HEALTH.
at5
owners, and to fill every local authority in the country with resentment and a determination to oppose to the utmost any Factory Bill that sought to deprive them of any share in the work of ensuring satisfactory health conditions for a great part of the population in the community they are elected to represent. By anyone, accustomed to the study o.f health reports, this of the Chief Inspector of Factories and Workshops breathes a hopefulness altogether new and strange. The only really sad note is that struck in reference to the resignation of Sir T h o m a s Legge, that sounded in respect of the general strike and the coal strike being" modified to show that, disastrous as these events may have appeared, the effects of the former particularly were short lived, and as a result of the latter, certain industries benefited. Also there has been considerable industrial development in a number of areas. In regard to industrial hygiene, diseases and accidents, there were improvements too, an increase in the number of casualties in the South-Eastern area of E n g l a n d arousing feelings of satisfaction as indicatingincreasing development in that neighbourhood. The total number of industrial accidents reported throughout the country was just under 140,000, some 20,000 less than in 1925. The number of individuals amongst whom these casualties occurred is not given, but the works or departments under special inspection total over 166,000, so that the proportion of casualties wo.uld not appear to be high. Of the accidents, 806 were fatal. F r o m t h e report it is gathered that in certain industries increased interest in prevention is being taken, both by employers and employees, and particular pressure is being brought to bear with a view to the protection of y o u n g and inexperienced workers. An extremely valuable section of the report, dealing with the y o u n g person in industry, is contributed by Miss Martindale, a D e p u t y C h i e f Inspector, who discusses such questions as the selection of y o u n g workers, the effect of industry on the health of y o u n g persons, as well as its influence on the mind, most interestingly and helpfully. So f a r as hygiene is concerned, evidence of considerable advance in most branches and areas is given, although u n d e r the head o f " Sanitary Accommodation " it is surprising to read of a food factory in which cases containing p a r t l y manufactured food were discovered stored on
PUBLIC
impress its seriousness and the need for action. In his introduction to the report, Sir George Newman also insists that a serious view should be taken. Heart disease has a preeminence amongst " the captains of the men of Death " : its relative, if not its real, mortality is steadily increasing; half of its weight may fall upon aged, worn out and degenerated, hearts, but there r e m a i n s - t h e other half which fails upon childhood, on youth, on the young adult and those in early middle age whose hearts have been attacked as a result of an infective process, more particularly that of acute rheumatic fever, to which probably not less than 40 per cent of all deaths from heart disease may be ascribed. That the process is an infective one the report accepts, though it is admitted that there is as yet nothing definite in the shape of proof. W i t h o u t knowledge with regard to the actual causative factor it has been found possible to take preventive action, and with some success, in other diseases by levelling an attack against the conditions predisposing to infection. In acute rheumatism the same course should be open even though, as it unfortunately happens, many if not most of the factors appear to be social rather than what may be called sanitary. Unfortunate, because evils and defects in relation to s u r r o u n d i n g s are matters easily dealt with in comparison with malnutrition and maternal neglect. For the remedy or removal of the causes of bad housing conditions, of dampness even, if other measures t~ail, compulsion is available. Not so,however, in regard to the removal of tonsils, an operation for which, it is interesting to note, the report claims high prophylactic value, provided it is performed sufficiently early. Given education it might be found easier to ensure a more effective attack upon the predisposing causes, and education is set down in several places as one of the chief preventive weapons for use, not only against the infection but against the heart sequelze and the effects they may produce if neglected. The burden of the song of prevention is ever--begin with the beginnings. And if the beginnings were easy to find a n d the beginning easily made, the results in cases in which they have been possible show how hopeful the position might be. The difficulty lies in the puzzle of symptoms that the acute rheumatic processes and the cardiac infections present. Definitely members of the group of " silent sicknesses,!' even the skilled diagnostician may fail to
HEALTH.
SEre'EMBER,
detect them; save on the most searching investigatio.n. And only too. seldom is it upon the skilled diagnostician that reliance for a decision is placed. More usually it is to the mother, ignorant of necessity, and often, as has been shown, neglectful, that the victim and those who might help him must look for the signal. The difficulties associated to some extent may be met by talking and warning and by warning and talking again and again, and by advising repeated and periodic medical examinations. In these days in this country, up till the end of the school days at any rate, this is not too difficult to arrange, and what the report says in this regard is for the school medical Officer and others to note. He and they will note al~so what is said as to the necessities for the infected, and the results that h a v e been obtained from rest with medical and nursing care and supervision. T h e y will note that the provision for affording this treatment to all that require it is inadequate, and will lose no opportunity o f bringing home to those who can make good the deficiency what the investigation at St. Thomas's Hospital has shown : that " for every child fortunate enough to be admitted as an in-patient, there are two, three or even four children who need in-patient treatment and who do not get it." W h a t is true of St. Thomas's is true of the country as a whole : the proof that it is true is here in this report, that provides also p r o o f that there is need for action, and that the time for action is now. -g-
-a
-~
-g-
g-
Acute Rheumatism in Chil&en--The Bristol Scheme. S T the areas in which active A MstepsO N Ghave been taken in the direction of dealing with the problem of acute rhemnatism and its sequelae in children must now be included Bristol. Here there has been placed on a firm basis what f o r several years past has been an informal understanding between the school medical officer and certain members of the voluntary hospital staffs in the city, by which elementary school children with cardiac disease have been submitted to the latter for expert examination and report. The Bristol Education Committee have secured from the Bristol General Hospital permission to send children with actual or potential cardiac disease to a clinic to be held weekly under the direction of one of the honorary phys!cians to the hospital. Moreover, in the neighbouring counties of
192r.
PUBLIC
Gloucestershire, Somersetshire and Wiltshire, a similar plan is to be inaugurated. Physicians of experience in cardiac disease have agreed to undertake visits to centres at which groups of children will be assembled for examination and repo.rt. Arrangements have also been made whereby reports on cases of rheumatic heart disease in childhood discovered in the practices of private doctors, as well as in school clinics, may be collected and the conditions under which the disease arose investigated by the county medical officers in collaboration with t h e University of Bristol Institute of Cardiac Research, which is housed at the Bristol General Hospital. Finally, as an inevitable development of this assembling and scrutiny of cardio-rheumatic children, the new hospital school about to. be built at Winford, on the outskirt.s of Bristol, and facing the Mendip Hills, is to include provision for the treatment of rheumatic heart disease in those children who need prolonged c0nrses of institutional care. The scheme for the entire area has received the sanction of the Board of Education, and is believed to be the most extensive of its type in E n g l a n d at the present time.
Health in the Factory. during the last four or five, or A Tit intervals may be more years, the country has been s h a k e n by the tidings that presently there would be passed into law a Factory Act that, by excluding local health authorities and their officers from factories and workshops, would ensure that these places were palaces of health and fit to labour in. No later than the beginning of July of this year, the H o m e Secretary, in the course of his Presidential Address at the Congress of the Royal Sanitary Institute, after a number of neat compliments to sanitary inspectors and medical officers of health--in that order--and a description of the manicure rooms and other wonderful things he had seen in certain establishments, declared his intention to delay no further, but to place on the Statute Book a piece of factory legislation that he himself felt to be long overdue. Now there has just been issued the annual report of the Chief Inspector of Factories and Workshops for the year 1926, which gives rise to no feeling but one of wonder that it should have been necessary for anyone to talk so much of the need for a new measure, to arouse alarm in the minds of all factory
HEALTH.
at5
owners, and to fill every local authority in the country with resentment and a determination to oppose to the utmost any Factory Bill that sought to deprive them of any share in the work of ensuring satisfactory health conditions for a great part of the population in the community they are elected to represent. By anyone, accustomed to the study o.f health reports, this of the Chief Inspector of Factories and Workshops breathes a hopefulness altogether new and strange. The only really sad note is that struck in reference to the resignation of Sir T h o m a s Legge, that sounded in respect of the general strike and the coal strike being" modified to show that, disastrous as these events may have appeared, the effects of the former particularly were short lived, and as a result of the latter, certain industries benefited. Also there has been considerable industrial development in a number of areas. In regard to industrial hygiene, diseases and accidents, there were improvements too, an increase in the number of casualties in the South-Eastern area of E n g l a n d arousing feelings of satisfaction as indicatingincreasing development in that neighbourhood. The total number of industrial accidents reported throughout the country was just under 140,000, some 20,000 less than in 1925. The number of individuals amongst whom these casualties occurred is not given, but the works or departments under special inspection total over 166,000, so that the proportion of casualties wo.uld not appear to be high. Of the accidents, 806 were fatal. F r o m t h e report it is gathered that in certain industries increased interest in prevention is being taken, both by employers and employees, and particular pressure is being brought to bear with a view to the protection of y o u n g and inexperienced workers. An extremely valuable section of the report, dealing with the y o u n g person in industry, is contributed by Miss Martindale, a D e p u t y C h i e f Inspector, who discusses such questions as the selection of y o u n g workers, the effect of industry on the health of y o u n g persons, as well as its influence on the mind, most interestingly and helpfully. So f a r as hygiene is concerned, evidence of considerable advance in most branches and areas is given, although u n d e r the head o f " Sanitary Accommodation " it is surprising to read of a food factory in which cases containing p a r t l y manufactured food were discovered stored on