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

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London County Council 1912

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

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Annual Report o] the London County Council, 1912.
Compared with the figures given in the annual report of the Medical Officer (Education) for 1909,
this shows a relative diminution in the number of cases of tuberculous disease and an increase in those
of infantile paralysis and heart disease. Special attention has been paid to the physical condition and
educational progress of the latter class of children, who may be grouped into categories according to
the nature of the lesion.
The first class includes the important group of children who have no organic valvular lesion, but
whose heart muscle has been weakened temporarily as a result of some acute illness, usually of an infectious
nature, such as scarlet fever or diphtheria. After severe attacks of such illnesses, convalescence is
protracted and sudden violent exertion may be attended with serious danger to health or even to life, and
it is necessary that the re-establishment of school routine should be slow. Many physicians are disinclined
to allow school attendance or only permit attendance for an hour or two a day, or perhaps for
half-time only. These children are able to attend an invalid school. Many months may elapse before it is
possible for them to attend an ordinary school, where they are exposed to the exertion of games
and stair-climbing, and the value of the invalid schools is generally now recognised by the medical
staff of hospitals, who, from time to time, suggest that certain children, though unfit for the ordinary
school, might be admitted to a school for the physically defective. In many cases these children, who
constitute a small minority of the total heart cases in the special schools, are able to return to the
ordinary schools after a time ; but the return thereto depends on the age at which they are admitted to
the special schools.
The second class consists of children suffering from definite organic, usually valvular, lesions of
the heart. This group must be sub-divided into two groups, those with congenital lesions and those
in whom the lesion has been acquired as a sequel to some serious illness, such as chorea, rheumatic or
scarlet fever. In some case3 it is impossible to state with certainty the category in which a given
child should be placed. The ultimate prognosis in congenital cases is unfavourable, but a considerable
proportion of the children survive for many years after the school period, and the education they receive
not only adds to their happiness, but often enables them to contribute in some measure to their own
support by means of various light home occupations.
Cases of acquired heart disease were found to constitute 86 per cent, of those of an organic nature,
the chief cause being a preceding attack of rheumatism or chorea. In connection with these cases, two
factors are of paramount importance—the prevention of fresh attacks of rheumatism and chorea which
would be accompanied by further damage to the heart, and the physical education of the damaged
heart muscle to enable it to overcome the mechanical difficulties associated with injured heart valves.
The risk of recurrence of rheumatism and chorea can be appraised only in general terms. The
more remote the original attack the less likely a recurrence, and the younger the child at the date of
the first attack the more likely is it to be subject to recurrences. Exposure to damp predisposes to
rheumatism, while long hours of ordinary school subjects have been found to encourage chorea. Hence
it is that the travelling to school in an ambulance and the spending of half the day in manual occupations
have a preventive function. A case in which the rheumatic condition has once returned is much
more unfavourable than one in which there has been a single attack only, so that care is desirable for a
long period after the original attack, in order to avoid such an untoward event. The prospects of health
tor a rheumatic subject with a damaged heart turn largely upon the choice of occupation, for exposure
and strain may lead to the early ending of a life which in sheltered and sedentary surroundings might
wall have attained the average expectancy. Cases are on record in which advice as to occupation on
leaving school has been neglected, and the subject has died within a short period; while others, instead
of being able to earn a partial living, have been converted into confirmed invalids.
An investigation into the prospects of children in the schools showed that nearly half had a
reasonable chance of looking forward to a normal existence if they were able to take ordinary care.
A study of the causes of prolonged absence of children from school shows that heart disease is
responsible for about 10 per cent., and the increase in the numbers attending is largely due to the more
general realisation of the advantages of the invalid schools, so that children now attend who at one
time were kept away under medical certificate, which could not have been contested successfully in
court. The children suffering from heart disease deemed suitable for the physically defective schools
are those in whom compensation has been but recently established or in whom there is a risk of recurrent
attacks of illness leading to further damage. Fully compensated cases with no recent rheumatic history
who are able to continue their ordinary occupations are not deemed suitable for admission.

Mr. Elmslie has the following record of children who have been in the schools for the physically defective at some period during the years 1908-1912 inclusive.

Admitted for observation; no heart lesion subsequently detected63
Non-valvular heart lesions with a rheumatic history95
,, ,, ,, without ,, ,, ,,53
Adherent pericardium6
Congenital heart disease118
Valvular lesions743
Comprising Mitral stenosis26
Mitral incompetence536
Double mitral108
Aortic and mitral41