View report page

99
that from all the infectious fevers together, but in the past teachers have been instructed chiefly in
the early detection of fevers. Their failure to observe, or at least to interpret, the early signs of
chorea in their pupils has received unfavourable medical comment.
Cases of habit spasm, of little importance, they are prone to refer to the school physician, but
the change in disposition and the first movements of the early choreic case are passed over, until a
frank attack necessitates several months away from school. This criticism does an injustice to the
better type of teacher, who may well look to the medical profession for the instructions—such as is
contained in the leaflet cited—on which to build an understanding of rheumatism as a disease process,
and of the early signs and symptoms of its manifestations.
Treatment—(during active phases of the disease).
Home.—Thomson's words deserve quotation—" For the vast majority of rheumatic children
satisfactory treatment at home is simply impossible. A busy mother of the artisan class can hardly
be expected to keep at rest a child who makes no complaints of ill-health and who to ordinary observation
appears quite well. Even if, in exceptional cases, she can be made to understand the need for
rest, it is almost impossible for her to make the necessary arrangements. If the child is strictly
confined to bed it rapidly becomes peevish and neurotic, and it must be remembered, too, that the
environment of the home is frequently one that actually predisposes to rheumatism. If the child
is allowed up (as they nearly always are) it is probably worse off playing about the house and neighbourhood
that it is at school, provided that the teacher is informed that the child is rheumatic and
requires special supervision." And Sir George Newman's—"Acute rheumatism and chorea are diseases
for which the provision of institutional treatment is particularly important. Few diseases are
less suited for home treatment in the kind of home in which the patients usually live—the bustling,
noisy, crowded and often insanitary homes of the poor in our great cities. Moreover, it has been
shown, and may be accepted as proved, that in the present state of our knowledge the liability to recurrent
attacks of acute rheumatism and to permanent heart damage is considerably diminished by a
prolonged convalescence, a convalescence of a kind unobtainable in the ordinary working-class home."
It is this unsatisfactory influence of the home environment except under unusual circumstances
that militates against the success of treatment by private practitioners or the out-patients' departments
by hospitals. Nevertheless at present it is almost inevitable that most children with mild attacks
of rheumatism, whether with chorea or with slight heart changes, or both, should remain at home, for
lack of appropriate institutional accommodation. By keeping the patient at rest in a living room
during the day, mental depression is less likely than if an attempt is made to keep it in bed.
Hospital.—" The treatment of acute rheumatism must be directed towards securing and
maintaining rest. This should be followed by the prevention, or failing that, the limitation of cardiac
involvement, the amelioration of cardiac disability and the treatment of sequelae. Cases of acute
rheumatism should receive prolonged hospital treatment. General hospitals, children's hospitals
and the Guardians' hospitals all take their share in the care of rheumatic children, and it is to their
work we owe much of our knowledge of aetiology, treatment and after history of the disease. But
hospital accommodation is limited and it is unfortunately impossible for the hospital owing to pressure
on its beds to give children the prolonged rest and treatment essential after the acute stage has
passed. Accordingly a child must be discharged during its convalescence, to return not infrequently
to a poor home where indifferent feeding, faulty hygiene, and the harassing life in the midst of a large
family are the very conditions which favour a recrudescence of the disease." (Sir George Newman)
The deficient accommodation in general hospitals for rheumatic cases is familiar to all medical
men. But this deficiency results from a present forced misuse of the beds in such hospitals. If
after the acute phase cases could be transferred for convalescence elsewhere, the general hospitals
could effect a far greater turn over of cases taken in for just that period when their particular contribution
of expert nursing is required. The convalescent rheumatic case does not need general
hospital nursing, but the alternative at present is so often only the ill-equipped home of the child,
that out of pity it is kept in and " blocks " a bed, that might have been given to another acute case.
Dr. F. J. Poynton writes:—
In private practice we should not dream of choosing a hospital ward in this part of London for a slow convalescence.
We need auxiliary hospitals, because skilful supervision is required, and rheumatism is notoriously
treacherous. It is not only fresh air and sun that I look for in these hospitals. Rest is a necessary part of the treatment
of rheumatic heart disease ; but blind unreasoning rest is bad—for there is no better tonic for the young heart
than exercise, and convalescence from rheumatic carditis should be a history of graded exertion and not aimless rest.
The auxiliary hospital can supervise these graded exercises with every hope of success. The ultimate goal is plain—
it is to send the child back to its home with a heart strengthened to the level of carrying on ordinary life ; and if
that is unattainable to ascertain the limitations and advise the parents."
It was a consideration of the unsatisfactory results of home treatment, and the lack of hospital
and convalescent homes where education could be continued, that led Dr. A. P. Thomson, Special
School Medical Officer, Birmingham, to suggest in 1921, that the Baskerville Residential School at
Harborne should reserve places for rheumatic children and gradually almost the whole of the accommodation
which allows for 100 children has been devoted to such cases.
Because of the importance of such pioneer efforts, his description of the administration of this
school, written in 1926, is followed in extenso.