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and muscular tone by suitable diet and regulated outdoor exercises ; that the treatment does not so
much consist of restraining the child from ordinary activities of life as in avoiding those conditions
which tend to precipitate a further attack of rheumatism or other infectious disease."
The rheumatic child may be away from school for 3 months or more, with an attack of chorea.
On returning to school, it is well for both parents and teachers to remember that the child is still
nervous and very sensitive to reproof or punishment. Overwork at school seldom if ever causes chorea,
but fear of punishment or actual punishment not infrequently aggravates the nervous condition.
Relapses are quite common, and if the child has been punished at school shortly before the relapse,
parents not unnaturally attribute the fresh attack to the punishment. Children who are convalescing
from an attack of chorea are often backward in their lessons, due to loss of memory and absence from
school. They lack precision in manual work through want of co-ordination, and they are sometimes
very troublesome through loss of self-control. Due allowance must be made for these deficiencies and
possibly it is best to keep these children in a small class at an open-air school until the nervous
system is in a more normal condition.
(b) Special Schools.—A certain number of rheumatic cases find education in certified special
schools, open-air schools, cripple schools and hospital schools.
Of the total accommodation in these schools—in England and Wales—day schools 9,854 places,
and residential schools 5,339 places—only a small minority are rheumatic or cardiac
cases.
(1) Hospital Schools.—Are " for education, and treatment of non-pulmonary tuberculosis and
other crippling defects." It would appear that rheumatic cases would benefit especially from life
in an institution where routine is devised for their special needs, such as at Baskerville; such institutions
are ideally to fit their patients for a more or less normal life at an ordinary school. Such schools have
been described above.
(2) Cripple Schools.—Are "for children suffering from crippling defects or weak hearts."
No treatment other than exercises is provided, so that only a certain class of rheumatic case is suitable
—one in which the rheumatic infection is quiescent but where the heart has been permanently damaged
so that modified ordinary life is unsuitable.
(3) Sir George Newman draws attention to the fact that rheumatic children, including those
suffering from chorea, do not as a rule do well at open-air schools.
When at school regular examination of the children by the school or other doctor, say every
three months, and the intelligent co-operation of parent and teachers is most desirable.
Periodical examination and The Rheumatic Register.—Sir George Newman, reporting in " The
Health of the School Child," 1924, advised as follows :—
" The School Medical Officer should establish a register of all the children suffering from the
principal manifestations of rheumatism (cardiac disease, chorea, and arthritis). Such
children should be individually studied and kept under supervision."
In Willesden no ad hoc register of these children is kept, but each case after being found at
routine medical inspection or clinic consultation is followed up automatically, as in any other class of
case, if it fails to return to see the Assistant School Medical Officer according to instructions.
The institution of such a register might be of benefit, however,
(1) In obviating any leakage of far greater import in rheumatism than in the generality of cases.
(2) In calling attention to the prevalence of the disease, instructive to the school and other
physicians as well as to parents, teachers and administrators.
(3) In permitting routine intimation to the Head Teacher concerned who would then be prepared
for advice in regard to the special management, if any, required by the child.
(4) In expediting action by the sanitary authority in dealing with dampness in the dwelling,
if present—-Or as a cogent reason why that family should change its dwelling, if by any means possible.
It is advised that the register should include the names of suspected cases and confirmed cases
separately grouped.
The Medical Inspection card should carry a numbered item " Rheumatism," and an entry made
there by the doctor even on slight suspicion, to allow of the case being carried to the Register.
The writer believes that a Register and space for a Rheumatic entry on the Medical inspection
card would achieve far more in the control of rheumatism at present than any general notification
required under a Public Health Act.
An efficient school medical service should be able to secure that all cases apart from gross
parental neglect are under some sort of regular supervision. Can the school medical service attempt
to be medically responsible for all rheumatic cases which have no private physician ? This is
doubtful as at present organised.
The writer holds that it would be most desirable that all school medical officers should be
expert in the diagnosis and supervision of rheumatic cases. But such is not yet, and the consultant
has a part to play.
This question of the most feasible and efficient form of after-care supervision is an important
one. Matters of financial stringency, actual and potential vested interests, and public apathy, jostle
one another in impeding development.
At Paddington Green Children's Hospital an effort has been made to meet this need, and the
terms of the descriptive leaflet are given below. Emphasis is laid upon the fact that the services
rendered are to supplement those of the customary physician of the patient, and there seems no
reason why a similar collaboration with the school medical service should not be successful in other
areas.