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in connection with those earlier stages of the disease when the very diagnosis hangs in doubt. It
is thus claimed that the school, physician should be at least an expert in detecting possible cases of
rheumatism as he meets them at routine inspections and at the clinic.
What can he do with such suspects ? His duty is to refer them for confirmation of the diagnosis.
It must be insisted that these cases are not primarily cases of heart disease but rheumatism, and that
among institutions, a clinic for children's diseases rather than a cardiac clinic is indicated. The
out-patient's department of the children's hospitals or of the children's departments of general
hospitals offer expert facilities in diagnosis and a certain oversight of treatment for those who cannot
afford good private advice. At present in the absence of any working arrangement between the
school medical officer and the specialist, the education authority only learns by chance, or at least
informally, of the suspect's condition and the measures advised. The same ignorance naturally
surrounds those cases for which private practitioners become responsible.
For no apology is required when insisting upon the importance of sound advice, based upon a
detailed careful physical examination and subsequent oversight at regular intervals. Until the
medical profession and the public look upon rheumatism with the same dread as they do upon cancer,
casual treatment will persist. Now the management of a case suspected or definitely labelled rheumatism
is a long business. It is not only the treatment of this one " attack " that interests the
school Medical Officer—the label must be attacked throughout school life. Consequently the unsatisfactory
elements in the present arrangements are constantly before him. To remedy this in
co-ordination is a point of administrative importance.
The writer as a school physician has had excellent results when Willesden children in whom he
has suspected rheumatism have seen at hospital consultants with whom he is on terms of friendship.
They have written confirming the diagnosis and stating that treatment is being undertaken or making
other suggestions. But this purely personal method cannot be generally employed. And yet it is
necessary that the consultant on children's diseases should play his part in the scheme, and a willing
part. Certainly a note from the hospital Almoner to the School Medical Officer at the first visit of
any suspect or diagnosed case of rheumatism would be of real value.
The suspicion has been entertained that influences are at work to seize upon rheumatism and
remove it from general hospitals and consultants even as Tuberculosis was taken and surround it
with a similar administrative barrier. This, some suppose, would be to the great hurt of all concerned,
patients, teaching schools and therefore general practitioners, and consultants.
After-care.
After care is required for two separate considerations:—
(1) To adjust the school life of the individual from time to time to any permanent damage
to the heart suffered in a previous attack.
(2) To maintain a constant watch against relapses.
The ideals of management may well be (1) to allow the child's education to deviate as little as
possible from the normal, having a strict regard for the capability of the heart. There is an inevitable
atmosphere of invalidism in a special school, which should only be used for cases in which the heart
is permanently crippled, or in the case of hospital schools, whilst the heart is being consolidated.
(2) To maintain " a follow-up " system so efficiently that all cases are known to be constantly under
observation by the school medical service.
The Educational institutions available are:—
(a) Ordinary elementary schools.—Most children after an attack of rheumatism, if properly
treated and with suitable convalescence, are fit to return to ordinary school. The heart
may be undamaged, or at least is competent to engage in the ordinary activities of
school life. Drill, games and such occupations as laundry work may have to be prohibited.
Dr. Allan Warner gives the following practical advice:—
" Broadly speaking, in early heart disease some outdoor exercise such as walking or cycling
(not against a strong wind or up a steep gradient) is distinctly beneficial, but the more
strenuous games such as football, cross-country running, or swimming are inadvisable.
The Swedish exercises given in our schools are not very strenuous, and the majority of
children at school who have some cardiac lesion may take the drilling lessons with
advantage."
Even cases with a murmur due to organic heart disease. " Where there is not much enlargement
of the heart and where the murmer is not much increased by exercise, may be allowed to drill provided
that they are kept under observation."
" When any heart weakness exists, the teachers should be informed of the case so as to obtain
their co-operation in the treatment of the child in school. Less exercise should be given or entirely
stopped if the child complains of feeling the strain of drill or shows any marked distress. In some
cases it is well to start with quarter-time drill, then increasing after examination to half time and
gradually to full time. Many cases of atonic hearts or of functional weakness are ameliorated or even
made normal by such a process. In all cases of organic disease the parents should be told of the
condition, care being taken not to cause unnecessary alarm. There is a prevalent idea that persons
suffering from heart disease are liable to sudden death. If this view is held by the parents it is well
to point out to them that sudden death from this cause, apart from congenital disease, is almost
unknown in children ; that the special care that these children require is the maintenance of nutrition