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effect of the malformation is so slight that they may pass through life with little
incapacity ; such are to be found in the ordinary elementary schools.
The acquired cases comprise those whose heart lining and muscular wall have
been damaged as a result of previous illness, though this may have been so slight as
to have attracted little attention. In this type the most important point, from
the standpoint both of cure and prevention, is to secure care under healthy conditions,
with graduated exercise and adequate rest, as soon as possible after the acute attack.
The first stages of this care can, without doubt, be better carried out in a residential
institution or in a convalescent home, than in a day school of any kind, though the
supervision afforded by the school is better, in many cases, than the complete freedom
which follows when children, not having been admitted to institutions or homes,
remain at home on genuine certificates of invalidity, but are sent out to play by
their parents. Formerly comparatively few cases were presented for admission
to special schools at the very earliest phase, though matters in this respect are improving
through the greater co-operation between the hospitals and the Children's
Care Organisation. There are now arrangements whereby certain hospitals notify
cases of rheumatism, in which event the children are kept under observation and,
in some cases, the Children's Care Organisation are able to assist in the matter of
convalescence and the like. Whenever a child is likely to do better in a day school
for the physically defective, special arrangements are made for its examination for
this purpose. Some of the best results have followed the admission of children to
the physically defective school after attacks of rheumatism or chorea, when there
was only a lack of tone in the heart showing weakness of the muscle, but, as yet, no
valvular incompetence. Several such have been able, after a time, to attend the
ordinary elementary schools and to follow the full curriculum with safety. Others
have been able to leave school fit for employment, which would probably not have
been the case had they not received care in the critical years. The main reason
why a number of the heart cases leave thus is that rheumatism is a disease of the
middle and later periods of school life rather than of the earlier period, so that many
cases come to notice between the ages of 10 and 13, and so have reached the age
of 14 + before their heart musculature is restored to a reasonable state of normality.
Up to the present time, however, the majority of the children dealt with have come
up for admission at a later stage when the heart mechanism has been definitely,
and often, permanently, impaired, in some instances too late for any modification
of school work to be of avail, but in many still at a stage in which careful graduation
of exercise and compulsory rest at intervals may make all the difference to their future
prospects. For all of these a mid-day rest is most valuable. The aim of school
treatment in all these heart affections is to avoid sudden strains, and gradually
to accustom the heart to increasing efforts until the normal regime can be resumed.
Under supervision any signs of failing effort can be noted at once, and steps taken
to increase the rest, or, if the condition be more serious, to send the child back for
further medical treatment. Without such supervision the condition of strain
may remain and may have done material damage before it sufficiently attracts the
attention of the less observant Barents.

Since heart disease is often a sequel of rheumatism, the number of cases in any
given year will depend on the frequency of rheumatism in previous years. It is