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may be mentioned—" to sit for several hours in damp boots and clothes constitutes a
real danger to children many of whom are anaemic and under nourished and consequently
less able than a normal child to resist infection."
(3) Deal with Septic tonsils.—Apart from other considerations septic tonsils acquire an added
significance in view of the frequency of rheumatism, its dangers, its association with
such tonsils and the increasingly accepted view that their removal may prevent or at
least favourably modify subsequent damage to the heart.
II. Management of the Rheumatic Child.
This is at present of greater practical importance. In many cases the rheumatic child is
recognised before permanent damage is done and the proportion of cases thus taken in time should
increase as the medical profession succeed in enlightening the public. " Frequently the patient has
already been damaged and the most we can do is to stave off attacks. This limitation it is essential
to recognise, for at present we are unable to control rheumatic heart disease with any certainty."
When the nature of the disease is grasped, and especially its liability to relapse, the size and
complications of this problem are seen to be of a large order. The child must be discovered, treated,
and subsequently maintained for a long period of years under regular medical supervision.
Notification of rheumatism is not required by law and the application of this measure which has
been of great value in the control of other diseases does not find favour with most authorities at
present. The uncertainty and variety of its early manifestations rendering its existence in cases a
matter of opinion, the assumption that it is not infectious, and the limited institutional treatment
available are amongst the reasons urged against notification.
The three functions of discovery, treatment and after care, require some discussion. It must be
admitted that practice lags far behind knowledge both in respect of lack of machinery and in the
use of such machinery as is now available. Discovery and after care are of necessity bound up with
the school medical service whatever be the other agencies—and this includes the private practitioner—
that collaborate.
The Discovery of Rheumatism and the School Medical Service.
The responsibility for an increasingly effective control of this disease must depend more and
more upon this service, which ministers to the population so largely at risk—children of school age
attending state schools.
In the matter of discovery of the disease in its earliest stages school medical officers have
unrivalled opportunities. The children are theoretically accessible to their observation throughout
their school years. But apart from the teacher or parent frequently failing to give the school or other
physician an opportunity to make a timely diagnosis, say, of chorea, in its early stage, it is undoubted
that even the three routine medical inspections during the child's school life are not adequately
utilised for the detection of rheumatism. Dr. A. P. Thomson very justly writes of the service that
" the conditions of inspection do not in general permit very exhaustive examination of the individual
child, and inasmuch as the signs of rheumatism and early heart diseases are frequently unobtrusive
it is probable that many of the cases are missed or are simply placed in such categories as ' malnutrition,'
' anaemia ' or ' functional ' affections."
It is possible that some blame attaches to the unsatisfactory conditions under which the routine
examination of the children is conducted. Noise from the class rooms and from traffic without may
interfere with the examination of the heart. In school no couch may be available for the child to be
examined in the recumbent position, but a table is equally serviceable and can surely always be
obtained. It may be urged, too, that the number of cases to be seen within the time limits of the
session precludes a sufficient detailed examination. But it cannot be too strongly emphasized that
the school medical officer need not feel it incumbent upon him to diagnose rheumatism at the routine
examination of school ; he need only suspect it—pale child, " nervous," failing to gain weight, not
doing well in school, " growing pains," often septic tonsils, perhaps equivocal heart signs, perhaps
dwelling in a basement or damp house. He should then refer such a child to the school clinic (if any)
where it can be conveniently examined in more detail before advising its parent to seek treatment, or
directly to a private physician or hospital. In any case the name of such a child should be noted and
it should be inexorably followed up by the Service until it is known to be under treatment or to be
declared fit by a competent authority.
In fact it is probable that when the Service fails it is rather through the ignorance of its staff,
or perhaps to put it in more kindly fashion, lack of awareness to the importance and frequency of
rheumatism, and their failure to utilise the machinery available than because of the conditions of the
inspection. The school doctor probably fails like other medical men for the reasons given by Dr.
F. G. Poynton under the caption " imperfection in medical education."
There seems to me some difficulty in the pathways of students who desire to gain a real clinical
insight into the rheumatism of childhood. Except in the largest general hospital there is no great
opportunity for a student during his time in the wards to see many cases of acute rheumatic carditis,
and yet there is no doubt that at this age rheumatic heart disease requires unusually careful observation.
In the adult the later and closing chapters of heart disease are seen with their alarming and striking
symptoms ; in the child, the dawn of heart disease requires close attention and some special teaching
Recently this weak point has been strengthened by the greater attention paid to children's disorders ;
in the final examination it will doubtless lead to general progress."
And if such criticism is just in respect of physicians failing in their handlings of frank cases of
acute rheumatic carditis, it is reasonable to suppose that at least an equal lack of thoroughness is found