CARDIAC CLASSES 
AND THE 
CARE OF 
CARDIAC CHILDREN 
BOARD OF EDUCATION 
THE CITY OF NEW YORK CARDIAC CLASSES AND THE 
CARE OF CARDIAC CHILDREN THE/COMMITTEE FOR THE STUDY OF 
THE CARE AND EDUCATION 
OF 
PHYSICALLY HANDICAPPED CHILDREN 
IN THE PUBLIC SCHOOLS 
OF THE 
CITY OF NEW YORK 
Report of the Sub-Committee on 
CARDIAC CLASSES AND THE CARE OF 
CARDIAC CHILDREN 
THE BOARD OF EDUCATION OF 
THE CITY OF NEW YORK BOARD OF EDUCATION 
of the 
CITY OF NEW YORK 
JAMES MARSHALL, President 
DR. ALBERTO C. BONASCHI 
DANIEL PAUL HIGGINS 
ELLSWORTH B. BUCK 
MRS. JOHANNA M. LINDLOF 
WILLIAM R. CROWLEY 
JAMES G. MCDONALD 
DR. HAROLD G. CAMPBELL, Superintendent of Schools The Committee for the Study of the 
Care and Education of 
Physically Handicapped Children 
in THE 
Public Schools of tpie City of New York 
HON. JAMES MARSHALL, LL.B., Chairman 
President of the Board of Education, City of New York. 
MARGARET W. BARNARD, M.D. 
Director of Bureau of District Health Administration, Department 
of Health, City of New York. 
CONRAD BERENS, M.D., F.A.C.S. 
Chairman of the American Board of Ophthalmology, New York, 
N. Y. 
Surgeon and Pathologist, New York Eye and Ear Infirmary, New 
York, N. Y. 
Directing Ophthalmologist, Midtown Hospital, New York, N. Y. 
Consulting Ophthalmologist, U. S. Veterans Hospital, New York, 
N. Y. 
Consulting Ophthalmologist, New York Infirmary for Women and 
Children, New York, N. Y. 
Consulting Ophthalmologist, Woman’s Hospital, New York, N. Y. 
EDWARD M. BERNECKER, M.D. 
General Medical Superintendent, Department of Hospitals, City of 
New York. 
ARTHUR C. DeGRAFF, M.D., F.A.C.P. 
Samuel A. Brown Professor of Therapeutics, New York University, 
College of Medicine, New York, N. Y. 
Lecturer in Medicine, New York University College of Dentistry, 
New York, N. Y. 
Visiting Physician, Bellevue Hospital, New York, N. Y. 
Chief of New York University Cardiac Clinic, New York, N. Y. 
Chief of After-Care Clinic of Irvington House, New York, N. Y. 
Consulting Cardiologist, Nassau Hospital, Mineola, Long Island. 
Consulting Cardiologist, Meadowbrook Hospital, Hempstead, Long 
Island. 
Consulting Cardiologist, New York Infirmary for Women and Chil- 
dren, New York, N. Y. 
Consulting Cardiologist, St. Agnes Hospital, White Plains, New 
York. 
Consulting Cardiologist, Hackensack Hospital, Hackensack, New 
Jersey. 
BENJAMIN P. FARRELL, M.D., F.A.C.S. 
Formerly Surgeon-in-Chief, New York Orthopaedic Hospital, New 
York, N. Y. 
Professor Emeritus of Orthopedic Surgery, College of Physicians 
and Surgeons, Columbia University, New York, N. Y. 
Consultant, Englewood Hospital, Englewood, New Jersey. 
5 EDMUND PRINCE FOWLER, M.D., F.A.C.S. 
Consulting Otologist, Manhattan Eye, Ear, Nose and Throat Hospi- 
tal, New York, N. Y. 
Consulting Otologist, St. Mary’s Hospital for Children, New York, 
N. Y. 
Consulting Otologist, National Hospital for Speech Disorders, New 
York, N. Y. 
GEORGE H. HYSLOP, M.D. 
Attending Neurologist, New York Nerirological Institute, New York, 
N. Y. 
Neurologist, Memorial Hospital, New York, N. Y. 
Assistant Clinical Professor of Neurology, College of Physicians 
and Surgeons, Columbia University, New York, N. Y. 
Consulting Neurologist, New York State Reconstruction Home, 
West Haverstraw, New York. 
Consulting Neurologist, St. Agnes Hospital, White Plains, New 
York. 
Consulting Neurologist, Nyack Hospital, Nyack, New York. 
DAVID J. KALISKI, M.D. 
Syphilologist, Beth Israel Hospital, New York, N. Y. 
Formerly Assistant G. U. Surgeon and Surgeon-in-Chief, G. U. 
Clinic, Mount Sinai Hospital, New York, N. Y. 
WALTER 0. KLINGMAN, M.D. 
Associate Attending Neurologist, Neurological Institute, New York, 
N. Y. 
Associate Attending Neurologist, Babies Hospital, New York, N. Y. 
Assistant Physician, French Hospital, New York, N. Y. 
Consulting Neurologist, South Side Hospital, Bayshore, Long Island. 
Assistant Pediatrician, Vanderbilt Clinic, New York, N. Y. 
ELWOOD S. MORTON, M.D. 
Medical Officer-in-charge, Bay Ridge-Sunset Park Health Center, 
Department of Health, City of Neiv York. 
FRANK J. O’BRIEN, M.D. 
Director of Bureau of Child Guidance, Board of Education, City of 
New York. 
GEORGE T. PALMER, Dr. P.H. 
Deputy Commissioner of Health, Department of Health, City of 
New York. 
MARSHALL C. PEASE, M.D., F.A.C.P. 
Clinical Professor of Pediatrics, Post-Graduate Medical School and 
Hospital, Columbia University, New York, N. Y. 
Physician, Willard Parker Hospital, New York, N. Y. 
Consulting Pediatrician, Lutheran Hospital, New York, N. Y. 
Consulting Pediatrician, Jamaica Hospital, Jamaica, Long Island. 
Consulting Pediatrician, Fitkin Memorial Hospital, Asbury Park, 
New Jersey. 
Consulting Pediatrician, Monmouth Memorial Hospital, Long Branch, 
New Jersey. 
Physician, Babies Ward, Post-Graduate Hospital, New York, N. Y. 
6 HENRY A. RILEY, M.D, 
Neurologist, Neurological Institute, New York, N. Y. 
Consulting Neurologist, Reconstruction Unit, Post-Graduate Hospi- 
tal, New York, N. Y. 
Consulting Neurologist, Englewood Hospital, Englewood, New 
Jersey. 
Visiting Neurologist, Welfare Hospital, Welfare Island, New York, 
N. Y. 
JACOB THEOBALD, B.A. 
Assistant Superintendent of Schools, Board of Education, City of 
New York. 
ELIZABETH A. WALSH* 
Director, Bureau for Children with Retarded Mental Development, 
Board of Education, City of New York. 
HERBERT B. WILCOX, M.D. 
Director, New York Academy of Medicine, New York, N. Y. 
Professor Emeritus of Pediatrics, College of Physicians and Sur- 
geons, Columbia University, New York, N. Y. 
IRA S. WILE, M.D. 
Associate in Pediatrics, Mt. Sinai Hospital, New York, N. Y. 
Lecturer on Disorders of Conduct and Personality, Columbia Uni- 
versity•, New York, N. Y., Hunter College, City of New York, 
and Brooklyn College, City of New York. 
I. OGDEN WOODRUFF, M.D., F.A.C.P. 
President, New York Tuberculosis and Health Association, New 
York, N. Y. 
Professor of Clinical Medicine, College of Physicians and Surgeons, 
Columbia University, New York, N. Y. 
Medical Director, Bellevue Hospital, New York, N. Y. 
Educational Consultants 
JOSEPH J. ENDUES 
Chief of Bureau of Physically Handicapped Children, State Educa- 
tion Department, Albany, N. Y. 
NICKOLAUS L. ENGELHARDT, Ph.D. 
Professor of Education, Teachers College, Columbia University, 
New York, N. Y. 
MARGARET J. McCOOEYf 
Associate Superintendent of Schools, Board of Education, City of 
New York. 
GEORGE D. STRAYER, Ph.D. 
Director of Division of Field Studies, Institute of Educational Re- 
search, and Professor of Education, Teachers College, Columbia 
University, New York, N. Y. 
JOHN W. STUDEBAKER, LL.D. 
United States Commissioner of Education, Federal Security Agency, 
U. S. Office of Education, Washington, D. C. 
LEWIS A. WILSON, D.Sc., LL.D. 
Associate Commissioner of Education, State Education Department, 
Albany, N. Y. 
Director of the Study 
HAROLD W. McCORMICK, Ed.D, 
*Deceased April 16, 1940. 
•{•Retired January 84, 1941. 
7 Reports 
of 
The Committee for the Study of the 
Care and Education of Physically 
Handicapped Children 
GENERAL REPORT 
Physically Handicapped Children in New York City 
Other Reports of the Committee 
Edmund Prince Fowler, Sr., M.D, 
Chairman 
Acoustically Handicapped 
Children 
Cardiac Classes and the Care 
of Cardiac Children 
Arthur C. DeGraff, M.D 
Chairman 
Children With Speech Defects 
Walter O. Klingman, M.D. 
Chairman 
Children With Tuberculosis 
I. Ogden Woodruff, M.D. 
Chairman 
Epileptic Children 
George H. Hyslop, M.D. 
Chairman 
Open Air Classes and the Care 
of Below Par Children 
I. Ogden Woodruff, M.D, 
Chairman 
Orthopedically Handicapped 
Children 
Benjamin P. Farrell, M.D. 
Chairman 
Psychological Considerations in the 
Education of the Handicapped 
Ira S. Wile, M.D. 
Chairman 
The Education of Children in 
Hospitals and Convalescent Homes 
Marshall C. Pease, M.D. 
Chairman 
Visually Handicapped Children 
Conrad Berens, M.D, 
Chairman 
8 Sub-Committee for the Study of Cardiac Classes 
and Care of Cardiac Children 
ARTHUR C. DeGRAFF, M.D., Chairman 
Lecturer in Medicine, New York University College of Dentistry, 
New York, N. Y. 
Visiting Physicicm, Bellevue Hospital, New York, N. Y. 
Chief of New York University Cardiac Clinic, New York, N. Y. 
Chief of After-Care Clinic of Irvington House, New York, N. Y. 
Consulting Cardiologist, Meadowbrook Hospital, Hempstead, L. I. 
Consulting Cardiologist, New York Infirmary for Women and Chil- 
dren, New York, N. Y. 
Consulting Cardiologist, St. Agnes Hospital, White Plains, N. Y. 
Consulting Cardiologist, Hackensack Hospital, Hackensack, N. J. 
ADOLPH BERGER, M.D. 
Attending Physician, New York University Cardiac Clinic, New 
York, N. Y. 
Clinical Assistant Visiting Physician, Bellevue Hospital, New York, 
N. Y. 
Assistant in Medicine, Neiv York University College of Medicine, 
New York, N. Y. 
HERBERT CHASIS, M.D. 
Assistant Professor of Medicine, New York University, School of 
Medicine, New York, N. Y. 
Assistant Visiting Physician, Bellevue Hospital, New York, N. Y. 
Associate Chief, Nephritis and Hypertension Clinic, New York 
University Clinic, New York, N. Y. 
KATHERINE G. DODGE, M.D. 
Assistant Visiting Physician, Children's Medical Division, Bellevue 
Hospital, New York, N. Y. 
Chief of Children's Cardiac Clinic, Bellevue Hospital, New York, 
N. Y. 
Assistant Professor of Pediatrics, New York University School of 
Medicine, New York, N. Y. 
HARRY GOLD, M.D. 
Assistant Professor of Phamnacology, Cornell University Medical 
College, New York, N. Y. 
Associate Physician, Beth Israel Hospital, New York, N. Y. 
Associate Physician, Hospital for Joint Diseases, New York, N. Y. 
Attending Cardiologist, Sea View Hospital, Staten Island, N. Y. 
Chief of the Cardiac Clinics of Beth Israel Hospital and Hospital 
for Joint Diseases, New York, N. Y. 
Associate Attending Physician, Welfare Hospital, New York, N. Y. 
9 ALFRED G. LANGMANN, M.D. 
Physician-in-charge, Children's Cardiac Clinic, Vanderbilt Clinic, 
New York, N. Y. 
Attending Pediatrician, Babies Hospital, New York, N. Y. 
MARGARET MATHESON 
Secretary, Heart Committee of the New York Tuberculosis and 
Health Association, New York, N. Y. 
IRVING ROTH, M.D. 
Associate in Medicine, Assistant in Pediatrics, Physician-in-charge, 
Adult and Children’s Cardiac Clinics, Mt. Sinai Hospital, 
New York, N. Y. 
Clinical Professor, Internal Medicine, Polyclinic Hospital, New 
York, N. Y. 
Consulting Cardiologist, United States Public Health Service, New 
York City and vicinity. 
Educators Participating in the Study 
HAROLD H. ABELSON, Ph.D. 
Assistant Professor of Education, College of the City of New York, 
New York, N. Y. 
FRITHIOF G. BORGESON, Ph.D. 
Professor of Education, New York University, New York, N. Y. 
HERBERT B. BRUNER, Ph.D. 
Professor of Education, Teachers College, Columbia University, 
New York, N. Y. 
ORLIE M. CLEM, Ph.D. 
Instructor in Education, New York University, New York, N. Y. 
JOSEPH GEORGE COHEN, Ph.D. 
Chairman of Education Department, Director of Graduate Division, 
Brooklyn College, Brooklyn, N. Y. 
NED DEARBORN, Ph.D. 
Dean of the Division of General Education, Professor of Education 
in the School of Education, New York University, New York, 
N. Y. 
WILLIAM B. FEATHERSTONE, Ph.D. 
Professor of Education, Teachers College, Columbia University, 
New York, N. Y. 
MERLE E. FRAMPTON, Ph.D., LL.D., Litt.D. 
Professor of Education, Teachers College, Columbia University, 
New York, N. Y. 
Principal, New York Institute for the Blind, New York, N. Y. 
10 WILL FRENCH, Ph.D. 
Professor of Education, Teachers College, Columbia University, 
New York, N. Y. 
ALBERT J. HARRIS, Ph.D. 
Instructor in Education, College of the City of New York, New York, 
N. Y. 
GERTRUDE HILDRETH, Ph.D. 
Psychologist, Lincoln School of Teachers College, New York, N. Y. 
Instructor in Research Methods, Teachers College, Columbia Uni- 
versity, New York, N. Y. 
LAURA H. V. KENNON, Ph.D. 
Instructor in Education, Brooklyn College, Brooklyn, N. Y. 
JOHN K. NORTON, Ph.D. 
Professor of Education, Teachers College, Columbia University, 
New York, N. Y. 
ROBERT T. ROCK, Ph.D. 
Head of the Department of Psychology, Professor of Psychology, 
Fordham University, New York, N. Y. 
RUTH M. STRANG, Ph.D. 
Professor of Education, Teachers College, Columbia University, 
New York, N. Y. 
EGBERT M. TURNER, A.M. 
Associate Professor in Education, College of the City of New York, 
New York, N. Y. 
Physicians Participating in the Study 
JANET BALDWIN, M.D. 
Assistant Clinical Physician, Bellevue Hospital, New York, N. Y. 
Assistant Instructor in Pediatrics and Fellow in Rheumatic Fever, 
Bellevue Hospital, New York, N. Y. 
ROBERT C. BATTERMAN, M.D. 
Assistant in Therapeutics, Department of Therapeutics, New York 
University, College of Medicine, New York, N. Y. 
Assistant Visiting Physician, Welfare Hospital, New York, N. Y. 
Clinical Assistant Visiting Physician, Bellevue Hospital, New York, 
N. Y. 
Attending Cardiologist, New York University Clinic, New York, 
N. Y. 
Clinical Assistant Physician, New York University Clinic, New 
York, N. Y. 
OLIVE S. BOSWORTH, M.D. 
Adjunct Pediatrician, Mt. Vernon Hospital, Mt. Vernon, New York 
Clinical Assistant Physician, Bellevue Hospital, New York, N. Y. 
11 I. JAY BRIGHTMAN, M.D. 
Clinical Physician, Bellevue Hospital, New York, N. Y. 
Clinical Assistant Physician, New York University Clinic, New 
York, N. Y. 
FRANK A. CALDERONE, M.D. 
District Health Officer, Lower East Side District, New York, N. Y. 
CHARLES A. R. CONNOR, M.D. 
Adjunct Physician in Ccurdiovoscular Diseases, Attending Physician 
Cardiac Clinic, Lenox Hill Hospital, New York, N. Y. 
Attending Physician, New York University College Clinic, New 
York, N. Y. 
Assistant Visiting Physician, Bellevue Hospital, New York, N. Y. 
Instructor in Medicine, New York University College of Medicine, 
New York, N. Y. 
Cardiologist, Department of Health, New York, N. Y. 
NICHOLAS J. DiGREGORIO, M.D. 
Assistant Attending Physician, Long Island College Hospital, 
Brooklyn, N. Y. 
Assistant Attending Physician, Long Island College Division of 
Kings County Hospital, Brooklyn, N. Y. 
A. GERSON HOLLANDER, M.D. 
Assistant Attending Physician, Brooklyn Hospital, Brooklyn, N. Y. 
Assistant Visiting Physician, Kings County Hospital, Brooklyn, 
N. Y. 
Assistant Electrocardiologist, Kings County Hospital, Brooklyn, 
N. Y. 
Instructor in Medicine, Long Island Medical College, Brooklyn, 
N. Y. 
CHARLES KOSSMAN, M.D. 
Chief, 3rd Medical Cardiac Clinic, Bellevue Hospital, New York, 
N. Y. 
Assistant Visiting Physician, Bellevue Hospital, New York, N. Y. 
Chief, Vascular Disease, New York University Clinic, New York, 
N. Y. 
Adjunct Physician, Cardiovascular Disease, Lenox Hill Hospital, 
New York, N. Y. 
NATHANIEL F. KWIT, M.D. 
Adjunct Physician, Lebanon Hospital, Bronx, N. Y. 
Assistant Cardiologist, Lebanon Hospital, 0.P.D., Bronx, N. Y. 
NINA R. LIEF, M.D. 
Clinical Asst. Physician, Pediatrics, Bellevue Hospital, New York, 
N. Y. 
ROSA LEE NEMIR, M.D. 
Assistant Visiting Physician, Children's Medical Division, Bellevue 
Hospital, New York, N. Y. 
Assistant Professor of Pediatrics, New York University School of 
Medicine, New York, N. Y. 
12 HILBERT RANGES, M.D, 
Clinical Assisting Physician, Bellevue Hospital, New York, N. Y. 
Clinical Assisting Physician, New Rochelle Hospital, New Rochelle, 
N. Y. 
JULES REDISH, M.D. 
Clinical Assistant Physician, Bellevue Hospital, New York, N. Y. 
Clinical Assistant Physician, New York University Clinic, New York, 
N. Y. 
URSULA J. ROCHE, M.D. 
Assistant, Medicine, New York University Medical School, New 
York, N. Y. 
Junior Assistant Visiting Physician, Bellevue Hospital, New York, 
N. Y. 
O. ALLEN ROSE, M.D. 
Clinical Assistant Physician, 3rd Division, Bellevue Hospital, New 
York, N. Y. 
Assistant Adjunct Physician, Lenox Hill Hospital, New York, N. Y. 
Assistant Cardiovascular Clinic, Lenox Hill Hospital, 0.P.D., New 
York, N. Y. 
Assistant, Bellevue and New York University Cardiovascular Clinics, 
New York, N. Y. 
SIDNEY P. SCHWARTZ, M.D. 
Cardiologist and Associate Physician, Montefiore Hospital, New 
York, N. Y. 
WILLIAM RUSSELL SMITH, M.D. 
Assistant Attending Pediatrician, Vanderbilt Children’s Heart 
Clinic, New York, N. Y. 
Attending Pediatrician, St. Vincent’s Hospital, Nero York, N. Y. 
Attending Pediatrician, Misencordia Hospital, New York, N. Y. 
L. HOLLAND WHITNEY, M.D. 
Associate Attending Pediatrician and Chief, Children’s Cardiac 
Clinic, Brooklyn Hospital, Brooklyn, N. Y. 
Other Persons Participating in the Study 
ANTHONY LOWELL, 8.5., C.P.H. 
Assistant Statistician, New York Tuberculosis & Health Association, 
New York, N. Y. 
IRVING LORGE, Ph.D. 
Executive Officer, Division of Psychology, Institute of Educational 
Research, Teachers College, Columbia Univ., New York, N. Y. 
Associate Professor of Education, Teachers College, Columbia 
University, New York, N. Y. 
SAUL B. SELLS 
Instructor, Department of Education, Division of Graduate Studies, 
Brooklyn College, Brooklyn, N. Y. 
Chief, Planning Section and Technical Supervisor of Educational 
Research Projects, Education and Recreation District Office, 
Works Projects Administration, City of New York. 
13 Physicians Consulted by the Committee 
ARTHUR F. ART, M.D. 
Assistant Professor of Pediatrics, Northwestern University Medical 
School, Chicago, 111. 
H. WARREN BUCKLER, M.D. 
Chief, Division of School Hygiene, Dept, of Health, Baltimore, Md. 
T. HOMER COFFEN, M.D. 
Clinical Professor Internal Medicine, University of Oregon Medical 
School, Portland, Ore. 
WALTER S. CORNELL, M.D. 
Director of Medical Inspection of Public Schools, Philadelphia, Pa. 
OSWALD F. HEDLEY, M.D. 
Surgeon, U. S. Public Health Service, National Institute of Health, 
Bethesda, Md, 
J. G. FRED HISS, M.D. 
Professor of Clinical Medicine, College of Medicine, Syracuse Uni- 
versity, Syracuse, N. Y. 
HAROLD M. MARVIN, M.D. 
Associate Clinical Professor of Medicine, Yale University School of 
Medicine, New Haven, Conn. 
hugh McCulloch, m.d. 
Associate Professor, Clinical Pediatrics, Washington University 
School of Medicine, St. Louis, Mo. 
JONATHAN MEAKINS, M.D. 
Professor of Medicine, McGill University, Montreal, Quebec, Canada. 
Chief Physician and Director, Medical Department and University 
Clinic, Royal Victoria Hospital, Montreal, Quebec, Canada. 
E. STERLING NICHOL, M.D. 
Attending Physician in Charge of Cardiology Service, Jackson 
Memorial Hospital, Miami, Fla. 
JOHN A. OILLE, M.D. 
Assistant Professor of Medicine, University of Toronto, Faculty of 
Medicine, Toronto, Canada. 
INA M. RICHTER, M.D. 
Medical Director, La Loma Feliz School, Staff Member, Santa 
Barbara General Hospital, Santa Barbara, Calif. 
STEWART ROBERTS, M.D. 
Professor, Clinical Medicine, Emory University School of Medicine, 
Atlanta, Ga. 
14 JOHN J. SAMPSON, M.D. 
Associate Clinical Professor of Medicine, University of California 
Medical School, Berkeley, Calif. 
ROY W. SCOTT, M.D. 
Professor, Clinical Medicine, Western Reserve University School of 
Medicine, Cleveland, O. 
HOWARD B. SPRAGUE, M.D. 
Visiting Physician, House of Good Samaritan, Boston, Mass. 
LOUIS VIKO, M.D. 
Instructor in Medicine, University of Utah Medical School, Salt 
Lake City, Utah. 
PAUL DUDLEY WHITE, M.D. 
Physician in Charge of Cardiac Clinics and Laboratory, Massachu- 
setts General Hospital, Boston, Mass. 
FRANK N. WILSON, M.D. 
Professor Medicine, University of Michigan Medical School, Ann 
Arbor, Mich. 
15 TABLE OF CONTENTS 
I. Preface 18 
11. Introduction 19 
111. Historical Background 23 
IV. Description of Rheumatic Fever 31 
V. Plan of Investigation 43 
VI. Summary of Finding 
and Observations by Physicians 53 
VII. Summary of Observations by Educators 81 
VIII. Summary and Recommendations 91 
17 Preface 
f-pHIS statement of findings and conclusions of the com- 
-L mittee studying the problems of cardiac children is one 
section of the report of the Committee for the Study of the 
Care and Education of Physically Handicapped Children in 
the Public Schools of the City of New York. The Committee 
was appointed by the Board of Education in 1936. All of its 
inquiries, which extended over a period of more than three 
years, have been made by sub-committees. No appropriation 
was given the Committee for the employment of technical 
and clerical personnel. The studies were possible only be- 
cause of the voluntary assistance of physicians, educators 
and other specialists who have given much time and con- 
sideration to the problems presented by handicapped children, 
the provisions now made for them and the ways in which 
the existing program can be improved. Clerical and statistical 
help was provided by the Works Projects Administration and 
numerous philanthropic organizations. 
In addition to the persons listed in this report the 
Committee is indebted to the Superintendent of Schools, Dr. 
Harold G. Campbell, to the teachers and schools officials and 
others who have helped in the survey and to Mr, Frank 
Kiernan, Director of the New York Tuberculosis and Health 
Association. The Director acknowledges his personal in- 
debtedness to Dr. Lyman C. Duryea and to Dr. Robert T. 
Rock. Jr, Finally he is indebted to the Public Health Relations 
Committee of the New York Academy of Medicine which has 
critically reviewed this and the other reports of the Committee. 
Harold W. McCormick, 
Director. 
19 II 
Introduction 
ALTHOUGH the problem of cardiac children in the public 
schools with which this report deals, is a large one and 
has many ramifications it must be remembered that it en- 
compasses only a single phase of the larger problem of 
heart disease in children. Rheumatic fever and rheumatic 
heart disease represent a public health problem of the 
greatest magnitude which must be attacked from many 
angles. The report of the rheumatic fever commission of 
London, England*, illustrates this very clearly. Hospital 
facilities for those ill with active rheumatic fever; con- 
valescent homes, sanatorial care and foster homes for those 
in the recovery phase of the disease; readjustment of the 
home life and economic factors for those returning to their 
old environment; adequate medical supervision for those in 
the inactive phase; health education and intensified research, 
and many other phases of the larger problem must be con- 
sidered in relationship to the schools. It must be realized, 
then, that this report is in the nature of a partial presenta- 
tion—a single chapter as it were—of the whole story of 
heart disease in children. 
It follows, then, that whatever plan is finally evolved in 
the school system for handling these children it must be so 
made that it is closely coordinated with other features of 
the whole project. Closely fitting into any plan to care for 
the cardiac children in the schools must be the work of the 
New York Heart Association which through its various 
committees is able to see the problem in its entirety and to 
offer concrete suggestions on any phase of it. The New 
York Heart Association should therefore be consulted on the 
personnel of the Medical Advisory Committee that is recom- 
mended in this report. 
of Juvenile Rheumatism: The London County Council’s 
Rheumatism Scheme,” appearing in Annals of Rheumatic Diseases, 
July, 1939, London, England. 
21 This report will indicate that with a redistribution of 
funds now available in the budget it will be possible more 
adequately to care for a larger number of cardiac children 
in the schools. We should like to point out, however, that 
proper care of the cardiac children in the schools cannot 
be done without sufficient funds. The ridiculously low 
salary of $5.00 per clinic session for cardiologists as con- 
sultants in the Cardiac Classification Service leads to a 
rapid turnover in physicians and tends to wreck the program. 
It will be necessary to increase the number of school physi- 
cians and nurses. To what extent this must be done can 
only be determined when a complete register of all the 
cardiac children in the public schools is available. This 
report, therefore, in which many examples of inefficiency 
and waste are indicated in the present handling of the 
cardiac children in the public schools must not be taken as 
an excuse to reduce or to eliminate medical service to cardiac 
children. 
Arthur C. DeGraff, 
Chairman. 
22 11l 
Historical Background 
Introduction 
IN 1916 the newly formed Association for the Preven- 
tion and Relief of Heart Disease undertook, as one of 
its major objectives, a study of the problem of children 
suffering from cardiac diseases in the public schools of 
Greater New York. During the following year, the 
Association developed a research project which provided 
for an intensive study of the effects of segregation on a 
certain number of children in special classes, and the 
setting-up of a control group of children examined and 
permitted to continue attending regular schools in order 
to secure data on which to judge the comparative value 
of the two methods. A few months later, an experiment 
was put into operation in three public schools selected 
because they were conveniently located near the cardiac 
clinics of Mount Sinai, St. Luke’s and Post-Graduate 
Hospitals. Later a fourth cardiac class was opened in 
connection with the cardiac clinic at Beth Israel Hospital. 
This investigation was interrupted by the declaration of 
war by the United States in 1917. The project could not 
be continued as planned, but the original experimental 
classes continued and a few members of the Association 
carried on the work. Concurrently the Public Education 
Association organized a cardiac committee which gave 
evidence of the fact of civic interest in the cardiac prob- 
lem. With the discontinuance of the activities of the 
Association for the Prevention and Relief of Heart 
Disease, the Public Education Association made a study 
to determine the number of children suffering from 
cardiac diseases and endeavored to maintain the interest 
of the Board of Education in the problem. This study 
revealed that there were 791 children in two districts 
comprised of 31 schools. These findings prompted the 
23 Historical Background 
Public Education Association to request the Board of 
Education to appropriate $25,000 for the study of the 
cardiac problem. In 1920 a grant of $24,063.43 was ap- 
propriated and eleven classes were established. In this 
same year the research project was resumed by a sub- 
committee of the Association for the Prevention and 
Relief of Heart Diseases of which Dr. Robert H. Halsey 
was Chairman. 
After three years of close observation of the children in 
these classes, the Chairman of this Committee, Dr. 
Robert H. Halsey, reported to the Board of Education 
on July 19, 1923, that information had not been found 
to be conclusive for a final report upon the kind and 
amount of school work which children with cardiac 
diseases can do, nor upon the measures available to con- 
trol, abate, and prevent the damage of the heart in 
children of school age as well as those of pre-school age. 
It was recommended that the segregated classes be 
abolished, as they were considered unnecessary for 92% 
of the children. The report further pointed out that 
under the existing method of segregating cardiac children 
the cost of caring for each child each school year made 
it impossible to care for more than 500 children. It was 
observed that more accurate results could be obtained 
by examining these children in cardiac clinics than by 
the ordinary school examination. This result was sub- 
stantiated by the fact that with the same group of chil- 
dren, the clinical examinations established an incidence 
of 0,7% of actual organic cases, while the Bureau of 
Hygiene had established an incidence of 1.39% based 
on the findings of school physicians. 
It was noted that the Board of Education had appro- 
priated $75,000 and the Public Education Association had 
supplied funds in four years approximating $30,000, yet 
this aggregate sum would not have been adequate for the 
24 Historical Background 
study if it had not been supplemented by assistance from 
various other welfare agencies, such as the Children’s 
Aid Association, School Children’s Welfare League, phy- 
sicians of cardiac clinics, nurses and social workers. 
In this same year, the Assistant Director in charge of 
the Physically Handicapped, in a report to the Superin- 
tendent of Schools advocated the extension of segregation 
for cardiac children, and submitted data showing weight 
gains and similar improvements resulting from segrega- 
tion of cardiac children in special classes. 
On October 15, 1923, the School Committee of the Asso- 
ciation for the Prevention and Relief of Heart Disease 
submitted a second report to the Superintendent of 
Schools, in which it commented on the report of the 
Assistant Director, and reiterated its previous recom- 
mendations as to the care of cardiac children in the 
schools. It found that the report of the Assistant Director 
had not presented any new evidence and stated that her 
data on the progress of cardiac children due to better 
health conditions showed what could be done by provid- 
ing food, but “revealed nothing as to the betterment of 
a damaged heart.” 
The conclusions arrived at by the School Committee of 
the Association for the Prevention and Relief of Heart 
Disease in these two reports in the year 1923 advised 
changes in the system of caring for cardiac children in 
the public schools at that time. However, the segregated 
classes were continued and were endorsed by the Public 
Education Association. 
In January, 1926, a sub-committee of which Dr. William 
St. Lawrence was chairman reported regarding the 
special classes and presented certain recommendations. 
It provided for a districting of the city by the Depart- 
ment of Health with clinics in each district to act as con- 
25 Historical Background 
sultation and treatment clinics, with a physician in charge 
and nursing personnel to examine all school children. 
The plan also provided for the permanent organization 
of the School Committee to act “as a unifying influence 
throughout the city and serve as a clearing house for 
suggestions and criticisms from the district chiefs and 
to cooperate with representatives from the Board of 
Health and the Board of Education.” The Committee, in 
formulating the report in consideration of its experience 
of two and a half years, reiterated the opinion that the 
position taken by the Association in the past was a sound 
one and stated that the cardiac segregrated classes should 
be abolished and children classified as Potential Cardiacs, 
or Class I or HA, should be transferred to the regular 
classes; that permission should be given for all children 
in Class HA to be excused from fire-drill and to arrive 
and depart from school earlier than the rest of the chil- 
dren ; that a division of cardiac control should be created 
in the Bureau of Child Hygiene of the Department of 
Health; and that a plan should be formulated for a com- 
plete and accurate register of all cardiac children. A 
conclusion arrived at through this study was that the 
expansion of the segregated classes by the Board of 
Education is not warranted. 
In 1926, the Superintendent of Schools requested the 
Committee on Public Health Relations of the New York 
Academy of Medicine to make an inquiry and to submit a 
report on the segregation of cardiac school children. 
Their conclusions reaffirmed the several reports of the 
School Committee of the New York Heart Association 
(successor to the Association for the Prevention and 
Relief of Heart Disease). The report emphasized the fact 
that members of the Board of Education “evidently do 
not appreciate that segregated classes per se are not the 
aim, but afford a method of medical control and super- 
vision” and the fact that strict medical supervision was 
26 Historical Background 
needed most, rather than general medical advice. The 
Committee of the New York Academy of Medicine advo- 
cated the abolishment of the existing cardiac classes. 
However, apparently at this time, the status of the segre- 
gated classes for cardiac children was such in the opinion 
of the Board of Education that their continuance was 
warranted. 
A request from the Commissioner of Health, Dr. Shirley 
Wynne, in 1931, in regard to building a separate school 
for cardiac children attending Junior High School re- 
opened the problem and the limited study which had been 
planned was made. 
In May 1934, the School Committee of the New York 
Heart Association presented a report in three sections; 
namely, the medical requirements, the present status and 
the recommendations for the cardiac children in the 
New York Public School system. 
The medical requirements as formulated were based on 
the knowledge of rheumatic heart disease held at that 
time. The need for medical personnel to detect and to 
diagnose correctly cardiac diseases in school children was 
noted as of paramount importance. Other important 
factors to be noted in the medical supervision were listed 
as: detection of rheumatic activity, provision of the best 
possible hygienic facilities and recording of medical data. 
It was felt that adequate medical requirements should 
include transportation and special privileges for the 
cardiac child in school, as well as educational opportuni- 
ties for the cardiac child forced to remain away from 
school for a considerable length of time. 
The Committee was handicapped in determining the 
status of the cardiac child in school because official 
records were not made available to them. In a summary 
27 Historical Background 
of the status, it was noted that the estimate of the inci- 
dence of cardiac diseases made by the Board of Educa- 
tion was unreliable as a guide to the magnitude of the 
cardiac school problem; that the fifty-four segregated 
cardiac classes in New York City Schools provided transi- 
tory accommodations for about one thousand children; 
that the method of admitting children to these classes was 
faulty; and that the medical and nursing supervision in 
these cardiac classes was not uniform and not adequate. 
In conclusion the report stated: 
“In the light of the analysis embodied in this report and 
in view of our present understanding of the nature and 
clinical course of rheumatic fever the ‘segregated cardiac 
classes’ in the public school system have failed to provide 
satisfactory medical supervision for the cardiac child at 
school. Because of this, the School Committee cannot 
endorse the ‘segregated cardiac classes’ as constituted 
and conducted at present and cannot recommend their 
further extension to the Junior High Schools of New 
York City.” 
The Committee believed that it was expedient for the 
City to provide more adequate medical care for the rheu- 
matic cardiac child at school and therefore recommended 
that the Department of Education affiliate with several 
clinics recommended by the New York Heart Associa- 
tion wherein the children who are seeking admission to 
the special cardiac classes might be examined and classi- 
fied; that physicians be appointed in the Department of 
Health, who could visit the special classes and arrange 
for periodic reexamination and reclassification; that addi- 
tional nurses be provided for the cardiac classes; that 
school teachers assigned to cardiac classes have special 
training; that home teachers be provided for all Class 
118 cardiacs; and that the Board of Education provide 
physical facilities for the care of these children. 
28 Historical Background 
From research made in compiling this historical material, 
it is evident that no information is available on the actual 
increase of cardiac classes in chronological order, nor 
on the basis for the increase which has taken place since 
the first three segregated cardiac classes were organized 
in 1917 as part of a research project. It is apparent that 
these classes have increased without sufficient study of 
the medical requirements, evaluation of medical services 
rendered, or consideration of alternative methods. 
29 IV 
Description of Rheumatic Fever 
Introduction 
THE problem of heart disease in children is primarily 
that of rheumatic fever and rheumatic heart disease. 
Ninety-five percent of all heart diseases in childhood are the 
direct result of rheumatic fever. A greater difficulty is pre- 
sented in this disease than in the anterior poliomyelitis where 
after the disease has produced its paralytic effects no further 
damage is probable. The problem in rheumatic heart disease 
more nearly resembles that of tuberculosis where, too, we 
must be constantly on guard for a reactivation of the infec- 
tion. 
Therefore, a brief review of what is known of rheumatic 
fever and rheumatic heart disease will be presented. Rheuma- 
tic fever has no distinctive clinical pattern. It may simulate 
several of the acute or chronic diseases of childhood. It is 
treacherous because failing to follow a typical pattern, it 
may confuse the physician. Also it is dangerous because its 
onset is at times so insidious that it fails to arouse timely 
suspicion on the part of its victim or his family, who thus 
tend to delay seeking medical aid until the disease has made 
serious headway and has produced irreparable damage to the 
heart and circulation. 
Acute Aspects 
The more readily distinguishable and clear-cut features 
of the disease appear, as would be expected, during its 
acute flares. These are its more striking and dramatic 
episodes, in the course of which the patient is acutely 
ill and may be afflicted with serious symptoms such as 
high fever, migrating joint and muscle pains, rapid heart 
action, respiratory embarrassment, drowsiness, weakness, 
profuse perspiration and prostration. Such acute epi- 
31 Description of Rheumatic Fever 
sodes may differ from patient to patient in that one or 
another of the acute features mentioned may dominate 
the clinical picture. 
In one, for instance, the joint involvement may be very 
severe and disabling. Such joints are generally swollen, 
visibly red, and exquisitely tender to the touch. This 
severe “polyarthritic” form is not the rule in children. 
In others the cardiac inflammation may be so extensive 
and respiration become so labored and troublesome that 
life seems in the balance. Actually it is because rapid 
failure of the circulation is a serious threat in this type 
of case. In still others, symptoms of severe toxemia, 
such as headaches, drowsiness and a tendency to prostra- 
tion dominate the acute episode. 
Such acute phases of the disease may last from three to 
six weeks and usually leave the patient with marked 
weakness, loss of weight and a severe secondary anemia. 
These are troublesome consequences of the disease in 
that they tend further to embarrass the damaged heart 
which, in turn, being unable to carry on an efficient 
circulation of the blood, will impair the function of 
other important organs such as the lungs, liver and the 
kidneys. Because of this, the patient’s convalescent 
period may become protracted so that it may take several 
months before he will begin to appear even tolerably 
well. 
Recurrent Episodes 
Furthermore, patients convalescing from the disease 
always incur the hazard of a re-lighting of the patholog- 
ical process. Recurrent acute episodes are common and 
they may appear in cycles only a few months apart. 
Generally, such recurrent cycles are not quite as close. 
32 Description of Rheumatic Fever 
More often they are ten or twelve months apart. Some 
of these recurrent acute episodes being after-flares, as it 
were, may not seem as acute and may actually be of 
shorter duration than the initial attack. There is, how- 
ever, no strict rule to this relationship. There are cases 
in which the initial attack is quite mild, while the re- 
current flares are successively more and more severe, 
leading precipitously to a rapid and final break-down. 
Smoldering Phases 
As has been pointed out, not uncommonly rheumatic 
fever may have an insidious onset, run its course and 
produce extensive cardiac damage before it is recog- 
nized. This form of the disease follows a smoldering 
course without any acute episodes or only with mild or 
relatively inconspicuous flares which generally escape 
attention. Minor symptoms may appear from time to 
time. The disease may be manifested only by low grade 
fever, mild fleeting muscle or joint aches and, what of 
course the child’s parents will not detect, a quickening 
of the heart action. Though these manifestations be mild, 
the disease may nevertheless run a destructive course 
with progressive structural damage to the heart. 
As would appear from the foregoing, these smoldering 
forms of the disease, running a course which is chronic 
or sub-acute, lead to considerable confusion both in diag- 
nosis and prognosis. By virtue of their smoldering and 
seemingly innocuous course, they are prone to give the 
patient, his family and at times even the physician in 
charge, an utterly unwarranted sense of security. Because 
of the diversity of the minor symptoms which the disease 
may present, it tends to confuse diagnosis in that it may 
resemble any one of a large group of the milder diseases 
33 Description of Rheumatic Fever 
of childhood. In some, the disease is entirely overlooked 
and the behavior of the patient may be ascribed to a mere 
personality defect. 
A child, for example, harboring this smoldering form of 
rheumatic fever may appear fretful, indisposed, may 
have poor appetite and perhaps a fitful sleep. “Just a 
bad child,” an “anti-social child,” a “finicky, cranky 
child” or other such appellations may be heaped upon 
him. As one can readily imagine, parents or guardians 
may even deem it necessary to resort to corporal punish- 
ment, in order to “train him in discipline.” This is 
especially true in the case of rheumatic children suffering 
from mild, undetected chorea, a disease often character- 
ized by a temporary personality defect. 
If a rheumatic child, after months of such a smoldering 
illness, and particularly because of poor appetite, should 
lose considerable weight, he may be taken to the physi- 
cian as a problem in nutrition. Complete examination 
usually reveals a murmur and the heart disease will be 
recognized. Nevertheless, such a child may still be 
treated for his presenting symptom, the malnutrition, 
and the fact that he is a victim of smoldering rheumatic 
fever may be entirely overlooked. 
There are those in whom, as a result of rheumatic activ- 
ity, profuse nose bleeds are the only troublesome symp- 
toms. This, in fact, may be the first manifestation of 
the disease. Such patients often find their way to the 
nose and throat specialist and undergo treatment for a 
presumably local disease for months before the disease 
is recognized. 
One of the more common manifestations of smoldering 
rheumatic fever is the fleeting muscle or joint pain. 
Children having this symptom may develop a sudden limp 
and the advice of an orthopedist may be sought before 
34 Description of Rheumatic Fever 
a thorough medical study is instituted. In this connection 
it should be emphasized that, fortunately, the so-called 
“growing pain” in children is taken more seriously to- 
day ; and parents, in larger cities at any rate, seek 
medical advice frequently because of this symptom alone. 
Certain skin rashes may be the only evidences of 
rheumatic activity. Not infrequently rheumatic children 
are taken to a dermatologist or to a skin clinic where 
on the basis of the skin lesions alone the diagnosis of 
rheumatic fever is made. Extensive literature has ap- 
peared in recent years to guide us in the recognition of 
the skin manifestation of this disease. 
There are children in whom without any outstanding 
complaint and without any conspicuous fever severe 
cardiac inflammation may nevertheless be going on and 
failure of the circulation may be actually impending. 
Their only symptoms may be a protracted cough and 
some shortness of breath. Such patients may be sub- 
jected to a variety of cough mixtures for weeks or even 
months before the true nature of the disease is finally 
disclosed. 
Perhaps the most dramatic manifestation or, in other 
words, the symptom which leads to the most serious 
consequences in smoldering rheumatic fever is the 
“belly-ache.” Abdominal pain may be the only expression 
of an acutely inflamed heart, especially pericarditis. 
On the other hand, it may actually be the expression of 
an acute abdominal rheumatic inflammation. This 
symptom, if accompanied by fever and by an increase 
in the white blood cells, completes a diagnostic triad 
which has all the ear-marks of an acute appendicitis. 
Surgical operations have been performed and are still 
being done on patients with this urgent symptom- 
complex. In the absence of other symptoms of active 
35 Description of Rheumatic Fever 
rheumatism the hazard of overlooking an acute appen- 
dicitis justifies surgical intervention in many of these 
cases. 
The above examples of the diverse symptomatology of 
rheumatic fever might be multiplied. However, for the 
purpose for which they are here intended, they will serve 
adequately, it is hoped. The examples cited are amply 
illustrative of the utterly misleading clinical picture of 
this disease. Furthermore, they lend emphasis, it is be- 
lieved, to what has been pointed out at the outset, namely, 
that rheumatic fever is an elusive and treacherous disease 
and that in its less acute forms or during the intervals 
between its stormy and more characteristic episodes 
it may simulate many of the common diseases of child- 
hood. 
Method of Approach and Clinical Picture Evolved 
Rheumatic fever has long been a problem of great 
concern to the medical profession. In years past, 
rheumatic fever meant joint inflammation and, converse- 
ly, joint pains meant rheumatism. Cardiac involvement 
was spoken of as a complication. It required many years 
of concerted effort to reveal the whole disease. This has 
been accomplished as a result of continuous care and 
uninterrupted observations on large groups of patients 
followed consecutively through hospitals, convalescent 
sanatoria, cardiac clinics, school classes and the home. 
As a result of this type of study, in which the New York 
Heart Association has taken a leading part, the true 
picture of rheumatic fever has finally been disclosed. 
It has now become evident that rheumatic fever is a 
chronic protracted disease with intermittent acute 
episodes, an intricate symptomatology, diverse clinical 
36 Description of Rheumatic Fever 
manifestations and a fairly unpredictable course. The 
pathological involvement and the inflammation which it 
produces is widespread. It may affect any part of the 
body. The cardiac inflammation stands out as its most 
dramatic manifestation largely because any structural 
injury to this organ, interfering with its physiological 
function, will ultimately be reflected in a disorder of 
function in other important organs of the body, whose 
physiological integrity naturally depends upon an ade- 
quate and well-balanced circulation. 
Etiological Considerations 
Although as a result of intensive study for the past two 
decades we have been quite familiar with the natural 
history and the clinical manifestations of rheumatic 
fever in children, we are, as yet, seriously hampered by 
the lack of considerable important information. The 
etiology, the actual cause, of this disease is not as yet 
completely demonstrated although a large number of 
competent contributory causes are recognized. 
An underlying allergic constitution to bacterial toxins 
has been suggested as a possible cause of the disease. 
No virus has been implicated. The etiological role of 
Group A, hemolytic streptococcal infections, has been 
stressed repeatedly for many years; and this concept is 
continually gaining ground. Those who urge this hypothe- 
sis base their views on the great frequency with which 
streptococcal infections induce acute rheumatic episodes, 
on the occurrence of certain immunological responses on 
the part of rheumatic fever patients to certain substances 
elaborated by these streptococci, and finally on the recent 
demonstration of the prophylactic influence of sulfanil- 
amide in respect to upper respiratory hemolytic strepto- 
coccal infections and rheumatic fever. There is a strong 
37 Description of Rheumatic Fever 
probability that the etiology of rheumatic fever has 
multiple components and it is not unreasonable to assume 
that the disease may prove to be the result of the 
foregoing suggested causes. 
Prevalence and Incidence 
Although the actual mechanism of the pathogenesis has 
not been definitely established, we are aided considerably 
in the management of patients with rheumatic fever 
by data gathered in recent years with respect to certain 
factors in its distribution, its prevalence and its incidence. 
The disease, though present throughout the country in 
one form or another, is relatively more prevalent in the 
northeastern section of the United States and converse- 
ly it is encountered less and less commonly as we travel 
south and southwest. The numerical prevalence in 
different parts of the country has not been definitely 
estimated because the disease is not reportable and 
studies thus far have been confined to limited sections. 
Cities with large populations, especially eastern cities, 
have been most adequately investigated. In New York 
City, for example, it is estimated that children with 
rheumatic fever or those who have had it, as evidenced 
by residual cardiac damage, constitute approximately 
three-quarters of one percent of the school population. 
As to the age incidence of first affections of rheumatic 
fever in children, some statistical studies have shown 
that, although seven years is perhaps the age of highest 
incidence, approximately twenty-five percent of certain 
groups studied have had their first attack of the disease 
as early as five years of age. It has been shown, further- 
more, that recurrences, or acute flares of the disease, are 
very common and that they continue unabated up to the 
age of puberty. These observations are important in 
that they bring rheumatic fever into the foreground 
38 Description of Rheumatic Fever 
as a disease of childhood which takes its toll in ill health 
during the public school age. 
The Basic Problem at School Age 
The problem of these children resolves itself into various 
aspects; (1) That of the child with an active, acute 
infection, who should be in a hospital or sanatorium; 
(2) a subacute to chronic stage lasting several months, 
in which the child should be in a sanatorium, convalescent 
home or quiet in his own home; (3) a recovered or 
completely quiescent stage in which the heart may show 
no sign of damage but the child’s general status be one 
in which there is liability to a recurrence of rheumatic 
fever if he contracts hemolytic streptococcal infections 
of the upper respiratory tract; (4) a completely quiescent 
state, but with varying degrees of permanent damage 
to the heart. Children in this stage not only may show 
symptoms of a damaged heart and require special con- 
sideration because of these symptoms; but they also are 
very liable to recurrences of the more acute phases of the 
disease, which are usually preceded or accompanied by 
hemolytic streptococcal infections; and during these 
recurrences additional cardiac damage probably will be 
inflicted. In general, it may be stated that the ultimate 
degree of heart involvement is more or less proportional 
to the number and severity of attacks of rheumatic fever 
the young patient has suffered. The public school should 
deal only with children in the completely quiescent or 
recovered phases of the disease; but actually there are 
attending school many children with low grade active 
rheumatic infection; hence there should be diagnostic 
machinery to detect these cases and to refer the children 
to the proper agencies for treatment. Moreover, the 
great tendency for children in phases 3 and 4 (above) 
to suffer relapses after certain acute respiratory infec- 
39 Description of Rheumatic Fever 
tions indicates the desirability of having the same 
diagnostic machinery always available for studying these 
children whenever such acute respiratory infections 
appear. 
Public Health Aspects 
Rheumatic fever presents also certain important public 
health aspects. Its geographic distribution, as has been 
mentioned, indicates that a large section of our popula- 
tion is subject to the disease. Aside from this, however, 
it must be pointed out that within this large geographic 
section there are areas of condensation, “nests,” as it 
were, where the disease is particularly prevalent. These 
areas correspond to crowded sections of large cities, 
“waterfronts” and parts of cities designated as “slums.” 
These happen to be areas inhabited by the under- 
privileged of our population. This curious relationship 
has long been recognized and emphasized by the English. 
It was they who designated rheumatic fever as a disease 
of “poverty, ignorance and filth.” 
There is some evidence, from meager information to be 
sure, which indicates that rheumatic fever is also a 
transmissible disease. It has been demonstrated as far 
back as some twenty years ago that there is a distinct 
familial tendency in this disease. It has been pointed out 
that in certain families rheumatic fever affects several 
members of the same family with as great a frequency 
as does tuberculosis. 
Furthermore, there are authentic reports of minor 
epidemics of rheumatic fever. These reports are based 
upon observations in military barracks and schools 
where an unusually large number of cases were dis- 
covered at the same time among otherwise seemingly 
40 Description of Rheumatic Fever 
healthy subjects; but in practically all of these epidemics 
the rheumatic fever was preceded by hemolytic strepto- 
coccal infections of the upper respiratory tract. The 
seasonal incidence of rheumatic fever, namely, its in- 
crease during the first winter and early spring months, 
may at times assume epidemic proportions. 
Community Responsibility 
In the light of the manifold aspects enumerated in the 
foregoing, it would appear that rheumatic fever presents 
a community problem of considerable magnitude. Any 
serious endeavor to cope with a problem of so widespread 
a scourge as rheumatic fever clearly implies a major 
responsibility. In the aggregate it becomes a matter of 
providing adequate facilities for health supervision, 
education, vocational guidance and the rehabilitation 
from time to time of a child population, numbering in 
the thousands even in single communities. This responsi- 
bility must be met with the conscious realization of the 
facts that these children are victims of a chronic pro- 
tracted disease and that they are afflicted with a damaged 
heart, during their most important, their formative years. 
Nor is this quite sufficient. Attempts at adjustment must 
take into account certain environmental factors. The 
rheumatic cardiac child is soon entangled in problems 
that emanate from the home. In the course of years, 
families with rheumatic children undergo great hardship 
and not infrequently they bankrupt themselves in 
desperate efforts to save such children. Furthermore, 
the repeated acute flares of the disease to which these 
children are particularly vulnerable, bring with them a 
recurrent train of anxieties which, because of their 
cumulative effect, finally undermine the morale of the 
family and the patient. Anxiety neuroses soon color the 
41 Description of Rheumatic Fever 
entire clinical picture so that the appraisal of symptoms 
as well as all planning intended to meet the actual needs 
of the child, educational or otherwise, becomes exceeding- 
ly difficult. 
Clearly then, any community effort on behalf of our 
rheumatic cardiac child population must take into 
account the nature of all environmental factors which 
tend to influence the course of the disease and the 
behavior of the child. 
Approaching the problem of the rheumatic cardiac child 
with a clear understanding of these important factors, 
certain advantages will accrue in time which otherwise 
could not be realized. The community, for instance, will 
be able to direct its efforts intelligently in directions that 
will lead to the greatest ultimate good. The medical 
profession in pursuing the study of the disease will be 
aided by several well coordinated agencies. And, finally, 
rheumatic cardiac children will be afforded uninterrupted 
observation and continuous care from which they should 
obviously gain lasting benefits. 
42 V 
Plan of Investigation 
•"THE review of the School Committee of the New York 
Heart Association made in 1934 was limited to an in- 
quiry into the medical aspects of the care of cardiac children 
in the public school system. The administrative aspects of the 
problem were not considered. However, the report was not 
released because it semed more profitable to acquaint certain 
members of the Board of Education and the Department of 
Health with the findings. 
The Committee pursued this practice and in 1938 the 
Board of Education authorized the study of the present 
practices of caring for all physically handicapped children 
in the schools of Greater New York. The Committee for the 
Study of the Care and Education of Physically Handicapped 
Children was organized and the Committee to Study the 
Problems of Cardiac Children was designated as one of the 
sub-divisions. 
The Academy of Medicine, the five County Medical 
Societies, the Department of Health and the Department 
of Hospitals cooperated through members of their organiza- 
tions whom they designated to serve on the Committee. A 
number of prominent educators also agreed to give their 
services in this study. 
By means of this joint committee it was hoped to make 
possible the achievement of a thorough study of the present 
practices in caring for and educating pupils with cardiac 
disorders, and a review of the problem in the light of the 
experiences of educators and public health agencies. 
43 Plan of Investigation 
Magnitude of the Problem 
The factual data pertaining to the enrollment in the 
special classes are furnished only by the Board of 
Education. In 1939, the Cardiac School Committee of the 
New York Heart Association, after a year of study con- 
cluded that further investigation and more complete 
data were necessary before the problem could be ade- 
quately studied and a plan formulated. According to 
data supplied by the Board of Education in 1939, there 
were 2,251 children in 84 cardiac classes in elementary 
schools and convalescent homes, and 95 children on the 
waiting lists for these classes. 
There is a wide divergence in the estimates from various 
sources as to the actual number of children with heart 
diseases in the public schools of the city. In 1931-1932, 
a study made by the Diagnostic Cardiac Clinic of New 
York City was based on the examinations of children 
applying for working certificates; during this year, 
166,152 children applied for working certificates. Of 
this number, 1,432 children were referred to the cardiac 
clinic and 1,215 were completely studied. Of these, 528 
(or 43.5%) were diagnosed as having organic heart 
disease. Assuming the same percentage of heart disease 
among the unexamined group, the authors of the study 
estimated that the number among the 1,432 referred 
children would be 622 or 0.57% of the entire group of 
109,964. It was noted that this incidence is lower than 
the estimates of most surveys, although there were two 
factors in regard to the children in this study which 
might have been expected to raise the resulting incidence, 
namely: 1) the narrow age limits representing an 
adolescent group, and 2) the low economic status of the 
children. Although a higher estimate was given in other 
surveys, in a careful study made in Boston of 119,337 
school children between the ages of 6 and 15 years, the 
incidence was found to be 0.52%; in another study in 
44 Plan of Investigation 
New York City made by Dr. R. H. Halsey, the incidence 
was revealed as 0.5%. 
A group of 818 school children of the East Side Schools 
in New York City who were classified as “cardiac” in 
the school record, were reexamined by the staff of the 
Beth Israel Hospital Cardiac Clinic in 1932. Only 36 
in this group were found to have organic heart disease. 
Although this is a small series, the results are entirely 
in harmony with those of the other studies showing that 
the true incidence of heart disease among school children 
in New York City is between six and seven-tenths of one 
percent. 
Hence, in consideration of these figures and the total 
number of school children the closest approximation 
which can be made, is that there are 7,000 children 
suffering with cardiac diseases in the schools of the city. 
Therefore, according to official records, less than 25% 
of the cardiac children are receiving special care in the 
schools under the present plan. 
The special care being given at present, although it 
benefits only this small percentage of all the cardiac 
children in the public schools, is being maintained at an 
excessive cost; the exact figures are not available. 
Proposed Plan 
Having determined that certain data were necessary for 
a thorough study of the present practices for educating 
pupils with cardiac diseases, the Committee formulated 
a plan. 
It was proposed to determine the efficacy of the routine 
school health examinations by having a group of 5,000 
45 Plan of Investigation 
children, selected at random, examined by competent 
cardiologists to determine the actual incidence of cardiac 
diseases and the accuracy of diagnoses in regard to the 
number of children reported as cardiac, and the number 
of cardiac children not diagnosed. 
The examinations of this group would reveal: the degree 
(or severity) of cardiac diseases of these children; the 
educational supervision of all cardiac children in the 
public schools and an estimate of the personnel and 
facilities provided for the segregated classes. The 
development of standards for educational and medical 
care based on these data would result in the placement 
and in the supervision of cardiac children according to 
their health needs. 
It was believed that much additional information would 
be collated on familial tendencies, economic status, and 
the responsibility of the family physician in relation to 
the incidence of cardiac diseases in school children. A 
record of the natural history of rheumatic heart disease 
in school children and a register of cardiac children 
during their enrollment in the public schools would result. 
The real significance of the undertaking was not so much 
in the survey findings, important though they would be 
to the Committee, but in the impetus that the work would 
give to others to improve practices and services and 
advance the knowledge of how better to care for the 
school child handicapped by cardiac diseases. 
The financial support required for this study was to be 
reduced considerably because of the voluntary services 
of the committee of physicians and educators and the 
availability of the facilities of the cardiac clinics affiliated 
with the Committee on Cardiac Clinics of the New York 
Heart Association. Nevertheless, this study as outlined 
46 Plan of Investigation 
necessitated the employment of trained personnel for the 
medical examinations, educational evaluations and for the 
preparation of the report. It was estimated that $22,000 
would provide the data and the analyses required for a 
complete study. The Department of Education was 
unable to secure the sum necessary for the study outlined 
above. 
Plan Adopted 
Due to the lack of funds, the Committee of necessity 
abandoned the fact-finding project pertaining to present 
practices and agreed to furnish the Board of Education 
with a medical plan which would provide care for all 
cardiac children in school, including those in the second- 
ary schools as well as the elementary schools, those in 
hospitals, sanatoria, convalescent homes, and children 
confined to their own homes. This project was under- 
taken notwithstanding the fact that the Board of 
Education ultimately was unable to furnish either pro- 
fessional or clerical assistance for the development of 
such a proposal. 
The Committee concluded that to formulate such a plan 
it would be necessary to visit all the segregated classes 
as well as a representative number of schools in which 
cardiac children attend the regular classes. 
The Committee enlisted the services of 18 additional 
physicians who, with the members of the Committee, 
were prepared to visit all the cardiac classes in the Public 
School System in New York City. The schedule was so 
arranged that a physician was assigned the schools 
nearest his residence; however, this did not obviate the 
necessity of their traveling long distances to reach the 
schools. 
47 Plan of Investigation 
Each physician recorded a description of his school visit 
on a uniform record. This appraisal necessitated a 
lengthy conference with the teacher as well as with the 
principal. 
In scheduling these visits, the Committee followed the 
list furnished by the Board of Education. At the very 
outset, the physicians reported discrepancies regarding 
the location of the cardiac classes and of the schools 
which had been assigned from the Board of Education 
list. These inaccuracies were reported to the Director of 
the Division of Physically Handicapped Children and 
four new lists were eventually supplied. There was great 
variation noted in all of these lists. The following com- 
parison will serve to show that the lists varied as to the 
actual number of classes in existence at the present time: 
List 
Number of 
Classes 
Number of 
Schools 
Ist - 84. ..50 
2nd 93 55 
3rd not given.... 50 
4th 94 55 
It was found in carrying out this plan of investigation, 
that the information supplied was inadequate, incomplete, 
and in many instances incorrect. 
48 Plan of Investigation 
Examples of Inadequate and Incorrect Information 
List School Borough Errata 
2nd P.S. 42 Queens Inadequate address given 
2nd P.S. 17 Manhattan Incorrect address given 
2nd P.S. 202. Brooklyn Incorrect address given 
Ist, 2nd P.S. 198 Brooklyn Cardiac classes discontinued* 
Ist, 2nd - P.S. 215 Brooklyn Cardiac classes discontinued 
Ist, 2nd P.S. 26 Brooklyn Cardiac classes discontinued 
Ist, 2nd, 3rd...P.5, 66 ..Bronx Cardiac classes discontinued 
Ist, 2nd, 4th ...P.S. 9 Bronx Cardiac classes discontinued 
Ist, 2nd P.S. 39 Manhattan ...Cardiac classes discontinued 
2nd P.S. 68 Manhattan ...Cardiac classes discontinued 
2nd, 4th P.S. 152 Queens Cardiac classes discontinued 
Ist P.S. 11 Woodside Cardiac classes discontinued 
3rd, 4th P.S. 118 Queens Cardiac classes not listed** 
3rd, 4th P.S. 33 Manhattan Cardiac classes not listed 
3rd, 4th P.S. 226 Brooklyn Cardiac classes not listed 
Not listed P.S. 253 Not given Cardiac classes not listed 
Ist P.S. 32 Manhattan Incorrect address given 
2nd, 4th P.S. 68 Manhattan Incorrect address given 
2nd P.S. 215 Brooklyn Inadequate address given*** 
Not listed P.S. 18.... Richmond Cardiac classes not listed 
2nd P.S. 161 Brooklyn Incorrect address given 
*ln some instances the classes had been transferred to another 
school. 
** Reports were sent in by principals for cardiac classes in these 
schools. 
***Address given as: “P.S. 215, Avenue S, Brooklyn.” 
Frequent and persistent efforts to secure a correct list 
of the location of the cardiac classes were unsuccessful; 
each new list produced new inaccuracies. This fact 
limited the study to 68 classes for which complete data 
were available, estimated as 64% of the total number 
of classes. 
49 Plan of Investigation 
School Principals 
The principals of 44 schools in the five boroughs sub- 
mitted statistics on cardiac classes in their respective 
schools. A questionnaire was prepared by the Committee 
and distributed by the Board of Education for this 
record. This information has been tabulated and may 
be found in the following tables. 
School Nurses 
The school nurses submitted information on cardiac 
children attending regular classes in nineteen schools. 
This information was submitted on a special form. The 
services of the school nurses were made available through 
the cooperation of Miss Amelia Grant, Director of the 
Bureau of Nursing of the Department of Health. 
Cardiologists of Other Cities 
In order to correlate the cardiac school study in Greater 
New York with the practices in other sections of the 
United States, a communication was addressed to eminent 
cardiologists. This communication contained a brief 
summary of the study, a request for an outline of the 
medical requirements of the cardiac child in school, and 
an opinion on the following questions. 
(1) Do you believe that cardiac children should be 
segregated in school? If so, please state your 
reason. 
(2) Have you had special cardiac classes in the schools 
of your city? 
(3) If they have been discontinued, please state the 
reason. 
50 Plan of Investigation 
(4) If such classes have not been organized, please 
state the reason. 
Nineteen cardiologists throughout the country replied to 
these inquiries and their statements on the subject have 
been considered by the Committee in submitting the 
recommendations for this report. 
Conferences 
The plan of investigation also included conferences of 
the School Committee and its Sub-Committee, with the 
Public Relations Committee of the New York Academy 
of Medicine, the Executive Committee and the Council 
of the New York Heart Association, with members of 
the Board of Education, the Department of Health, and 
the faculties of Teachers College, Columbia University, 
New York University, Fordham University, City College 
of New York and Brooklyn College. 
51 VI 
Summary of Findings and Observations 
by Physicians 
Introduction 
AS outlined in the plan of investigation, the basic data 
contained in this study of cardiac school children are 
derived from reports submitted by principals of schools having 
special cardiac classes, by school nurses responsible for 
children in non-segregated classes, and by physicians who 
visited the schools. 
Location of Cardiac Classes in Public Schools 
Included in the survey are only those schools for which 
schedules with adequate information were submitted to 
the Committee. Consequently data were available on 
68 special classes in 41 schools; it is known that this 
number does not represent the exact number of schools 
with segregated classes. As shown in Table I, the major- 
ity of these classes are in schools in the boroughs of 
Brooklyn and Bronx, Brooklyn has 13 schools with 24 
segregated classes, and Bronx has 13 schools with 21 
segregated classes. Manhattan has 9 schools with 15 
segregated classes. The next largest number of segre- 
gated classes is in the borough of Queens, which has 6 
classes distributed in 5 schools; the borough of Richmond 
has 2 classes in 1 school. 
53 Observation of Physicians 
Table I 
Distribution by Boroughs of Cardiac Classes 
Studied by the Committee 
Borough • Schools Classes 
Manhattan 9* 15 
Brooklyn 13 24 
Bronx 13 21 
Queens 5 6 
Richmond - 1 2 
Total 41 68 
*ln addition there was one school schedule (Manhattan No. 32) 
eliminated because of incomplete information. 
Included in survey are only those schools for which schedules 
were available. 75 classes were selected for the study but data 
were obtained for only 68 of these classes. 
Age and Sex of Cardiac Children 
The distribution of children in cardiac classes by age 
and sex for the entire 68 classes is indicated in Table 11. 
This table also shows the distribution of cardiac children 
in these schools who were in regular classes at the time 
of the study. Six hundred-eighty-two or 45% of the 
segregated children are boys, 777 (52%) are girls; the 
sex was not stated in 48 instances (3%). Ages were 
given in all but one record, and ranged from 6 to 17 for 
the boys and 6 to 18 for the girls. About 80% of the 
group—l,2ll children—are between 9 and 14 as shown 
in Table 111, while the ages 12 and 13 have the greatest 
representation in both sexes. 
54 Age 
Male 
Cardiac 
Classes 
Female N.S. Total 
Male 
Waiting 
List 
Female N.S. 
Total 
Not in Cardiac Classes 
or on Waiting List 
Male Female N.S. Total 
Total 
Cardiac School Children 
Male Female N.S. Total 
5 
4 
2 
6 
12 
4 
2 
6 
12 
6 
5 
6 
11 
1 
2 
3 
22 
15 
11 
48 
28 
23 
11 
62 
7 
28 
20 
2 
50 
2 
3 
5 
34 
27 
13 
74 
64 
50 
15 
129 
8 
28 
43 
1 
72 
3 
2 
3 
8 
34 
S3 
17 
84 
65 
78 
21 
164 
9 
68 
55 
1 
124 
5 
3 
8 
38 
35 
20 
93 
111 
93 
21 
225 
10 
85 
94 
2 
181 
5 
9 
1 
15 
40 
28 
18 
86 
130 
151 
21 
282 
11 
82 
112 
4 
198 
7 
8 
3 
18 
52 
24 
10 
66 
121 
144 
17 
282 
12 
122 
129 
7 
258 
4 
7 
3 
14 
32 
13 
19 
64 
158 
149 
29 
336 
13 
108 
136 
13 
257 
3 
5 
2 
10 
28 
21 
20 
69 
139 
162 
35 
336 
14 
93 
91 
9 
193- 
7 
3 
3 
13 
21 
14 
11 
46 
121 
108 
23 
252 
15 
30 
58 
6 
94 
2 
2 
...... 
4 
11 
4 
14 
29 
43 
64 
20 
127 
16 
26 
24 
2 
52 
1 
3 
1 
5 
6 
3 
9 
33 
30 
3 
66 
17 
7 
8 
15 
2 
2 
9 
8 
17 
18 
1 
1 
1 
1 
N.S.* 
1 
1 
3 
4 
3 
10 
23 
27 
50 
26 
31 
4 
61 
Total 
♦N.S.- 
682 777 
-Not stated. 
48 
1507 
45 
51' 
19 
113 
527 
246 
159 
732 
1052 
1074 
26 
2352 
Table II 
Distribution of Cardiac Children by Age and Sex 
55 Observation of Physicians 
Table 111 
Distribution by Age of Children 
in Cardiac Classes 
Age 
Number 
Percent 
6 
11 
0.7 
7 
50 
3.3 
8 
72 
4.8 
9 
124 
8.2 
10 
181 
12.1 
11 
198 
13.1 
12 
258 
17.1 
13 
257 
17.1 
14 
193 
12.8 
15 
94 
6.2 
16 
52 
3.4 
17 
15 
1.0 
18 
1 
0.1 
Not Stated 
1 
0.1 
Total 
1507 
100.0% 
Number and Grade Distribution of Cardiac Classes 
The class standing was noted in 1,498 records. Only 2 
cardiac children are designated as academically ungraded 
while the vast majority receive formal instruction in the 
grades from 1A to 88. The composite distribution of the 
children by grades as presented in Table IV reveals that 
there is a gradual, practically linear increase in the 
cardiac census from 1A up to 88. It may be noted in Table 
V that 49 classes have 5 or more grades. Grade distribu- 
tion of cardiac children not segregated in special classes 
is shown in Table VI. Table VII on page 59 shows the 
age-grade distribution of children enrolled in the special 
classes. 
In the 41 schools visited there are 2,352 children con- 
sidered to be cardiac and 1,507 (64%) are segregated in 
the 68 special classes. The remaining 845 are enrolled 
in regular classes, with 113 (5%) awaiting admission 
to special classes as indicated in Table 11. A considerable 
mass of information was accumulated on all these 
56 Observation of Physicians 
Table IV 
Distribution by Grade of Children 
in Cardiac Classes 
Grade 
Number 
Percent 
1A 
28 
1.9 
IB 
23 
1.5 
2A 
49 
3.3 
2B 
50 
3.3 
3A 
55 
3.6 
3B 
76 
5.0 
4A 
90 
6.0 
4B 
96 
6.4 
5A 
106 
7.0 
5B 
111 
7.4 
6A 
135 
9.0 
6B 
143 
9.5 
7A 
151 
10.0 
7B 
109 
7.2 
8A 
170 
11.3 
8B 
104 
6.9 
Not Stated 
11 
0.7 
Total 
1507 
100.0% 
Table V 
Number of Half-Year Grades per Classroom 
in Cardiac Classes 
Number of 
Grades 
Per Class 
Manhattan 
B’klyn 
Bronx 
City- 
Queens Richmond Total 
1 
2 
2 
2 
3 
1 
3 
2 
6 
4 
4 
5 
9 
5 
2 
4 
1 
7 
6 
5 
1 
3 
2 
11 
7 
3 
1 
i 
5 
8 
3 
1 
4 
8 
9 
1 
1 
2 
2 
6 
10 
2 
3 
1 
6 
11 
1 
i 
2 
12 
1 
i 
2 
4 
Not Stated 
1 
i 
— 
2 
Total 
15 
24 
21 
6 
2 
68 
57 Grade 
Children on Waiting List 
Male Female N. S. 
Children Not on Waiting List Total Not in 
or in Cardiac Classes Special Classes 
Male Female N.S. 
1A 
5 
2 
13 
11 
8 
39 
IB 
1 
1 
15 
15 
7 
39 
2A 
1 
3 
2 
26 
14 
8 
54 
2B 
1 
3 
26 
13 
8 
51 
3A 
5 
2 
1 
20 
18 
9 
55 
3B 
4 
4 
24 
12 
6 
50 
4A 
1 
2 
1 
15 
25 
8 
52 
4B 
1 
5 
18 
14 
10 
48 
5A 
3 
5 
«... 
18 
20 
10 
56 
5B 
5 
1 
3 
16 
13 
8 
46 
6A 
4 
20 
17 
11 
52 
6B 
1 
3 
3 
14 
11 
6 
38 
7A 
2 
3 
2 
9 
7 
7 
30 
7B 
1 
3 
2 
21 
4 
11 
42 
8A 
4 
2 
16 
10 
10 
42 
8B 
2 
2 
1 
13 
14 
6 
38 
9A 
2 
1 
2 
5 
9B 
6 
2 
8 
Ungraded 
3 
5 
2 
26 
25 
14 
75 
Kindergarten 
— 
— 
7 
4 
8 
19 
Not Stated 
6 
6 
Total 40 
N.S.—Grade or Sex not stated, 
49 
24 
325 
248 
159 
845 
Grade Distribution of Cardiac Children Not Segregated in Special Classes 
Table VI 
58 Table VII 
Age-Grade Distribution of Cardiac Children Segregated in Special Classes 
Age 
in Years 
M. 
1A 
F.N.S. 
IB 
M. F.N.S. 
2A 
M. F.N.S. 
2B 
M. F.N.S. 
8A SB 
M. F.N.S. M. F.N.S. 
M. 
4A 
F.N.S. 
GRADE AND SEX 
4B 5A 
M.F.N.S. M. F.N.S. 
5B 6A 
M. F.N.S. M. F.N.S. 
6B 
M. F.N.S. 
7A 
M. F.N.S. 
7B 
M. F.N.S. 
8A 
M. F. N.S. 
8B 
M. F.N.S. 
Ungraded 
Not Stated 
Total 
6 
6 
4 .. 
.. 1 .. 
1 . . . . 
11 
7 
8 
5 1 
9 4 .. 
9 7.. 
2 4.. 
1 
60 
2 3 
6 9 
9 15 .. 
7 7 .. 
3 6 . . 
1 
3 . . 
.... 1 
72 
9 
2 .. 
i .. .. 
8 .. .. 
9 5 .. 
8 14 .. 
11 16 .. 
19 
10 1 
8 8 .. 
8 .. .. 
1 .. .. 
124 
10 
1 
i .. .. 
4 1 .. 
8 .. .. 
10 5 .. 
15 10 .. 
15 
12 1 
14 22 1 
12 25 .. 
5 12 .. 
5 6 .. 
.. 2 .. 
< 
181 
11 
2 2 .. 
12.. 
1 1 .. 
5 4 .. 
9 
6 2 
9 5 1 
9 15 .. 
15 23 .. 
18 25 1 
9 23 .. 
8 8 .. 
11.. 
.. 1 .. 
1 
198 
12 
.. 1 
ii.. 
1 1 .. 
3 3 .. 
4 
3 .. 
7 6.. 
15 8 .. 
15 21 .. 
20 16 .. 
29 21 1 
10 30 .. 
12 10 2 
8 8 1 
1 .. .. 
4 
258 
13 
1 
1 
2 .. 
4 2 .. 
6 6.. 
6 6.. 
10 19 2 
10 16 .. 
26 27 2 
13 18 1 
23 30 4 
8 11 3 
1 
257 
14 
1 .. 
2 1 .. 
8 1.. 
2 2 .. 
3 7 .. 
10 10 .. 
13 13 1 
12 15 2 
29 25 4 
19 16 2 
193 
15 
.. 2 .. 
.. 3 .. 
1 1 .. 
11.. 
5 3 .. 
3 11 .. 
3 6 1 
9 14 2 
8 17 1 
2 
94 
16 
1 .. .. 
.. 1 .. 
.. 1 .. 
1 .. 1 
2 .. .. 
6 2 .. 
17.. 
6 6.. 
10 7 .. 
1 
52 
17 
11.. 
2 .. .. 
11.. 
18.. 
2 2.. 
.. 1 .. 
•• 
15 
18 
1 
N.S.* 
1 
1 
15 
11 2 
14 9 .. 
30 19 .. 
24 26 .. 
27 28 .. 
87 89 .. 
49 
87 4 
46 47 3 
48 58 .. 
45 66 .. 
58 73 4 
67 75 1 
61 87 3 
43 60 6 
72 87 11 
46 52 6 
11 
Total 
28 
23 
49 
50 
55 
76 
90 
96 
106 
Ill 
135 
143 
151 
109 
170 
104 
11 
1507 
*N.S.—Grade, 
Sex or Age Not Stated Observation of Physicians 
children but since a prime reason for this study has been 
the role of the cardiac class in the care of the cardiac 
child, attention will be directed first to the facts pertinent 
to the special classes and the 1,507 children in them. 
Etiological Factors 
The information of most importance to those charged 
with the responsibility for such individuals is concerned 
with the etiology of the heart disease, and the effect of 
the etiological factors on the myocardial reserve. Etio- 
logical diagnoses, obtained from the individual “pink” 
medical records in the school files, and made in most 
instances in conformity with the criteria established 
by the Heart Committee of the New York Tuberculosis 
and Health Association, are available on 1,326 children 
(88% of 1,507 Table VIII). Dealing as the survey 
does with such a selected sample of the entire community, 
one would, a priori, expect to find a very high incidence 
of rheumatic heart disease, and almost complete exclusion 
of the degenerative or senescent types of change. Thus, 
under the rubric rheumatice fever are included 76.9% of 
the total group, or 1,159 children. Though some reports 
merely stated the etiological factor to be rheumatic fever, 
and others specified the inactive phase of the disease, both 
groups may be considered together. Strict adherence 
to the New York Heart Association criteria would de- 
mand a precise statement concerning the activity of the 
rheumatic process (insofar as this can be determined 
clinically) but it seems unlikely that a child with any 
manifestation of active rheumatic fever would knowingly 
be permitted to attend school. For the 68 classes, and 
allowing for the one individual whose age is not stated, 
the ages of the children with rheumatic heart disease 
range from 6 to 17. Eight hundred and fifty or about 
74% of 1,159 fall within the years 10 through 14 in- 
clusive, a distribution almost identical with the entire 
group of cardiac children. 
60 Etiology 
Manhattan 
Num- Ber- 
ber cent 
Brooklyn 
Num- Ber- 
ber cent 
Bronx 
Num- Ber- 
ber cent 
Queens 
Num- Ber- 
ber cent 
Richmond 
Num- Ber- 
ber cent 
City Total 
Num- Ber- 
ber cent 
Rheumatic Fever 
.. 233 
69 
275 
48 
283 
64 
91 
69 
26 
68 
908 
60.2 
Rheumatic Fever inactive 
. 55 
16 
126 
22 
42 
10 
21 
16 
7 
18 
251 
16.7 
Congenital 
30 
9 
32 
6 
41 
10 
10 
8 
3 
8 
116 
7.7 
Bacterial Infection 
3 
1 
3 
1 
1 
0.2 
— 
— 
— 
7 
0.5 
Others 
6 
2 
8 
1 
9 
2 
2 
1 
1 
3 
26 
1.7 
Unknown 
3 
1 
4 
1 
5 
1 
6 
5 
18 
1.2 
Not Stated 
8 
2 
121 
21 
49 
11 
2 
1 
1 
3 
181 
12.0 
Total 
*Item “A” on schedule. 
.. 338 100% 
569 100% 
430 100% 
132 100% 
38 100% 
1507 100% 
Distribution of Children in Cardiac Classes by Etiological Diagnosis* 
Table VIII 
61 Observation of Physicians 
Congenital developmental defects were responsible for 
heart disease 116 times (7.7%). The age range was from 
3 to 17, with 70% (82) found from 9 to 13. 
The remaining 51 individuals (3.4%) comprise a miscel- 
laneous group in which the nature of the etiological agent 
is not clear or is unknown. Heart disease was ascribed 
to bacterial infection in 7 instances, or 0.5% of the total. 
Whether this refers to or includes such conditions as 
healed bacterial endocarditis or the cardiac sequelae of 
diptheria, scarlet fever, etc., is not apparent. The term 
“other” is used 26 times (1.7%) and again the exact 
etiological agent is not given. Possibly, hypertensive 
heart disease secondary to chronic diffuse glomerulo- 
nephritis may be included here. Finally, the etiology is 
stated frankly to be unknown 18 times (1.2%). One 
might inquire if these are cases of the rheumatic type 
of heart disease in the absence of a history of well-defined 
manifestations of rheumatic fever, or if these are true 
examples of organic heart disease. 
At the time the material for this study was collected the 
latest revision of the criteria for the diagnosis of heart 
disease had not yet appeared and, hence, the functional 
classification of the cardiac children retains the old 
nomenclature. The composite figures for the entire city 
as given in Table IX indicate that the great majority 
of the children have mild diminution of their cardiac 
reserve, i.e., they are classified as IIA. This accounts for 
1,203 children, 79.8% of the total. The manner in which 
the designation IIA is arrived at for a given child, 
however, is open occasionally to some doubts. Such a 
62 Observation of Physicians 
classification may really have been the expression of a 
therapeutic approach to the child’s heart disease, or it 
may have been used to insure a child’s admission to a 
special cardiac class even though that child had no dimin- 
ution of cardiac reserve. Only 48 children (3.2%) had 
no limitations because of their disease and 157 (10.4%) 
had moderate to marked diminution of cardiac reserve 
(class IIB). The three children whose functional classi- 
fication is 111 present a problem, since such a designation 
indicates that the patient is bed-ridden. Likewise, the 
nine individuals included under the heading “other” pose 
a problem are they possible and potential cardiacs 
(E and F) or are they children with other diseases? 
In 87 records (5.8%) the functional classification was 
not given. This is a significant number inasmuch as an 
accurate functional classification is an important part 
of the record of children in cardiac classes. 
63  
Manhattan 
Brooklyn 
Bronx 
Queens 
Richmond 
City Total 
Functional Classification 
Num 
her 
- Per- 
cent 
Num- 
ber 
- Per- 
cent 
Num 
ber 
- Per- 
cent 
Num- Per- 
ber cent 
Num 
ber 
- Per- 
cent 
Num- Per- 
ber cent 
I - 
9 
2.7 
15 
2.6 
19 
4.4 
3 2.3 
2 
5.3 
48 
3.2 
IIA 
. 285 
84.3 
431 
75.8 
842 
79.5 
112 84.8 
33 
86.8 
1208 
79.8 
IIB 
32 
9.4 
74 
13.0 
32 
7.5 
16 12.1 
3 
7.9 
157 
10.4 
Ill 
~~ 
3 
0.7 
3 
0.2 
Others 
2 
0.6 
4 
0.7 
2 
0.5 
1 0.8 
9 
0.6 
Not Stated 
. 10 
8.0 
45 
7.9 
32 
7.4 
87 
5.8 
Total 
. 338 100% 
569 100% 
430 100% 
132 100% 
88 100% 
1507 100% 
Distribution of Children in Cardiac Classes According to 
Functional Diagnosis 
Table IX 
64 Observation of Physicians 
Table X 
Distribution of Children in Cardiac Classes 
by Functional Diagnosis and by Grade 
Grade 
Functional Classification 
I IIA IIB III Others 
N.S. 
Total 
1A 
1 
21 
3 
2 
1 
28 
IB 
1 
19 
2 
1 
23 
2A 
1 
41 
4 
3 
49 
2B 
39 
7 
4 
50 
3A 
49 
4 
2 
55 
3B 
2 
61 
6 
2 
5 
76 
4A 
1 
79 
8 
2 
90 
4B 
78 
10 
1 
1 
6 
96 
5A 
4 
79 
15 
8 
106 
5B 
4 
85 
13 
9 
111 
6A 
9 
102 
17 
7 
135 
6B 
8 
116 
17 
2 
143 
7A 
2 
128 
12 
1 
1 
7 
151 
7B 
5 
75 
14 
1 
1 
13 
109 
8A 
9 
139 
10 
2 
10 
170 
8B 
1 
83 
13 
7 
104 
Ungraded 
1 
1 
2 
Not Stated 
8 
1 
9 
Total 
48 
1203 
157 
3 
11 
85 
1507 
Analyzing the functional diagnosis by grades (Table X) 
it is interesting to note that 42 of the 48 children 
designated as Class I are found in the upper grades, and 
only 6 are found in the grades from 1A to 48. There is 
a gradual increase in the number of children labelled lIA 
throughout the academic grades. The functional diag- 
noses and ages of the children are compiled in Table XL 
65 Observation of Physicians 
Table XI 
Distribution of Children in Cardiac Classes 
by Functional Diagnosis and Age 
Age 
Functional Classification 
I IIA IIB III 
Others 
N.S. 
Total 
6 
8 
3 
11 
7 
1 
40 
7 
2 
50 
8 
2 
55 
8 
1 
6 
72 
9 
3 
109 
8 
4 
124 
10 
2 
159 
11 
1 
1 
7 
181 
11 
9 
147 
30 
12 
198 
12 
11 
202 
27 
1 
2 
15 
258 
18 
6 
204 
27 
1 
3 
16 
257 
14 
5 
154 
23 
1 
10 
193 
15 
5 
76 
5 
1 
7 
94 
16 
3 
37 
8 
4 
52 
17 
1 
10 
3 
1 
15 
18 
1 
1 
Not Stated 
— 
1 
1 
Total 
48 
1203 
157 
3 
9 
87 
1507 
Medical Care 
The care of cardiac school children is a joint medical 
and educational problem. It is interesting that 741 
children (49%) are under the care of clinics or hospitals, 
many of which are affiliated with the New York Heart 
Association. The records of 682 children (45%) indicate 
private medical care while no information on medical 
supervision is available on the remaining 84 (6%). From 
these records, it is impossible to determine the amount 
and nature of the medical supervision, whether it is 
continuous or merely an examination. Presumably the 
children enrolled in clinics affiliated with the Heart 
Association were given periodic, and frequent, careful 
medical supervision. 
66 Observation of Physicians 
Special Cardiac Teachers 
The major role in the actual handling of cardiac children 
is played by the teacher for it is she who has daily contact 
with her charges. To perform such a job efficiently and 
intelligently demands some insight into the nature of the 
problem and some training in addition to that afforded 
by the routine courses offered to prospective teachers. 
The questions intended to elucidate this matter of special 
training and experience of the teachers revealed the most 
uniform aspect of the cardiac classes. Over 92% of the 
teachers (63 out of 68) had taken, while in training, 
some type of special work at Hunter College. Thirty-five 
of the 63 teachers specifically stated that they had taken 
one or more courses given by the Assistant Director in 
charge of Physically Handicapped, while the remaining 
28 merely indicated some special courses. Direct inquiry 
into the nature of all these courses did not yield much 
information apparently, all these courses consisted of 
very rudimentary anatomy and physiology and an 
occasional visit to a cardiac clinic. Only one teacher did 
not take some sort of special training for her work and 
in three records no mention was made of training. Not 
quite half of the instructors (30 out of 68) had three 
years or less experience in teaching cardiac classes; the 
remaining 38 indivduals had served special classes for 
periods of four to twenty years. The matter of a sub- 
stitute in case of the absence of a special teacher was 
not investigated routinely, though in two instances, it 
was learned definitely that no provision is made for 
substitutes. 
67 Procedures Reported 
Manhattan 
B’klyn 
Bronx 
Queens 
Richmond 
Total 
Temperature and Pulse 
5 
4 
1 
2 
12 
Temperature only 
4 
— 
4 
Pulse only 
2 
6 
9 
— 
— 
17 
Taken irregularly or omitted 
No statement 
8 
17 
1 
8 
1 
34 
1 
Total 
15 
24 
21 
6 
2 
68 
Temperature and/or Pulse Record Taken by 
Manhattan 
B’klyn 
Bronx 
Queens 
Richmond 
Total 
Teacher 
4 
6 
11 
5 
2 
28 
Nurse _ 
3 
2 
5 
Total 
7 
6 
13 
5 
2 
33 
Classroom Procedures Followed in Recording 
Temperature and Pulse 
Table XII 
68 Observation of Physicians 
Class Room Management 
An important group of questions pertinent to the detec- 
tion of colds, or other symptoms of active periods of 
disease and what care was given when such signs were 
detected, were designed to reveal the efficiency of the 
functioning of the special classes. 
It has been indicated that rheumatic fever is the main 
etiological factor responsible for heart disease in the 
school child. The protean manifestations of rheumatism, 
the frequency of an insidious onset, and the common 
association with respiratory infections, render its early 
detection difficult even for the trained observer. Never* 
theless, the admittedly inadequately trained teacher is 
confronted with the problem of searching out occult 
rheumatic fever. To accomplish this the temperature, 
the pulse rate or both were taken in 33 classes as shown 
in Table XII. Both the temperature and the pulse were 
recorded in 12 classes, the former alone in 4 classes, and 
the latter alone in 17 classes. Teachers made the obser- 
vations in 28 classes and the school nurse, in 5 classes. 
The pulse was counted and/or the temperature was 
determined irregularly, e.g., only if indicated, or omitted, 
in 34 classes. 
Table XIII 
Criteria for Detecting “Rheumatism” 
Criteria 
Manhattan 
B’klyn 
Bronx 
Queens 
Richmond 
City 
Total 
Subjective complaints of child* 6 
17 
12 
5 
40 
Teacher’s observation of 
child 4 
5 
5 
— 
— 
14 
Temperature rise 
— 
— 
— 
1 
— 
1 
Pulse 
— 
— 
1 
— 
— 
1 
None or not stated .. 
5 
2 
3 
— 
2 
12 
Total 
15 
24 
21 
6 
2 
68 
♦Joint or muscular pains, fatigue, etc. 
69 Observation of Physicians 
In Table XIII, the criteria for detecting rheumatism 
represent the teacher’s observations of the children’s 
complaints. The most commonly encountered complaints 
are joint or muscle pains, fatigue and malaise. The 
precise meaning of “teacher’s observation” of child is 
not apparent, though 14 teachers used such “observa- 
tion,” to detect rheumatism. The temperature and the 
pulse rate were used as criteria only once each. 
In the event that a case of rheumatism was detected, 
there was a great divergence of the policy followed, as 
indicated in Table XIV. No provision was made for such 
a child to be examined directly by a physician. Fourteen 
teachers notified the parents and suggested medical 
checkup, though the time and manner of such notification 
were not stated. Twelve teachers apparently referred 
the child to a medical agency. Sixteen teachers indicated 
that they would send such a child home, again suggesting 
medical care. The onus of responsibility was passed to 
the school nurse by 16 teachers, leaving her to notify 
the parents or arrange for medical follow-up. While 
some action would be taken in most instances, the lack 
of a consistent, well-directed policy is evident. 
70 Procedure 
Manhattan 
B’klyn 
Bronx 
Queens 
Richmond 
Total 
Parents notified and check up by physician or clinic 
suggested 
— — 
9 
5 
— 
— 
14 
Referred to physician or clinic 
5 
7 
12 
Sent home (medical care usually suggested) 
1 
5 
7 
3 
16 
Nurse called (parents notified, etc.) 
5 
9 
1 
1 
.... 
16 
Others* 
1 
1 
1 
2 
5 
Not stated 
3 
1 
1 
5 
Total 
15 
24 
21 
6 
2 
68 
♦Principal notified, segregated, clinic visit suggested, 
etc. 
Procedure Followed When “Rheumatism” is Detected 
Table XIV 
71 Observation of Physicians 
The criteria employed by 63 teachers for detection of 
colds in cardiac children (Table XV) were: cough, 
coryza, malaise, sore throat, temperature, “running nose,” 
etc., either alone or in combination. These symptoms and 
signs are notoriously non-specific since they may be 
encountered in ordinary respiratory infections, as pro- 
dromata of the acute exanthemata or in allergic condi- 
tions of the upper respiratory tract, yet they serve their 
purpose if they raise the teacher’s index of suspicion. 
Table XV 
Criteria for Detecting Colds 
Criteria 
Man. 
B’klyn 
Bx. 
Qu. 
Rich. Total 
No statement 
15 
24 
16 
6 
2 63 
Sent to nurse if cold suspected 
1 
1 
Observation of “signs” by teacher* 
4 
-- 
4 
Total 
15 
24 
21 
6 
2 68 
* Cough, coryza, malaise, sore throat, temperature, “running nose,” etc., 
any one or a combination of symptoms. 
The immediate procedure upon detection of a cold was 
found to be variable, as shown in Table XVI. “Isolation” 
of the child was done in 35 classes, though the exact 
nature and efficiency of this procedure is doubtful. 
Twenty-two teachers placed the child either in a far 
corner of the room or close to their own desks, and 11 
more teachers, in addition to such a procedure, referred 
the problem to the principal or nurse. In 16 classes any 
child found to have a cold was sent home. 
72 Procedure 
Manhattan 
B’klyn 
Bronx 
Queens 
Richmond 
Total 
Isolated in corner of room 
4 
10 
6 
2 
22 
Isolated and referred to Nurse or Principal 
2 
4 
2 
1 
2 
11 
Temperature taken and referred to Principal, Nurse, 
or Physician -... 
2 
4 
...... 
6 
Sent to Nurse - 
1 
— 
2 
1 
...... 
4 
Sent to Nurse only occasionally - 
— 
2 
2 
2 
2 
Sent home 
4 
11 
1 
— 
16 
1 
1 
2 
1 
1 
4 
Total 
15 
24 
21 
6 
2 
68 
Immediate Procedure Followed Upon Detection of “Cold” 
Table XVI 
73 Upon a child’s return to school, following an absence, 
it is proper that the cause for such absence be checked 
and an effort be made to determine whether there has 
been any change in the individual’s medical diagnosis, 
including functional capacity. In 34 classes some attempt 
to check the diagnosis was made by the teacher, nurse, 
physician or clinic agency, in casual fashion. One third 
of the classes (23) made no effort to check the diagnosis. 
(Table XVII) 
Observation of Physicians 
Confirmation of Medical Diagnosis Upon Child’s 
Return to School. 
Table XVII 
Confirmation of Diagnosis 
Man. B’klyn 
Bx. 
Qu. 
Rich. 
Total 
Diagnosis checked by teacher 
1 
2 
3 
Diagnosis checked by nurse 
2 
i* 
3 
6 
Diagnosis checked by clinic or physician 
4 
16 
4 
24 
Diagnosis checked but method not stated 
1 
1 
Checked only occasionally 
2 
2 
4 
Not checked 
7 
13 
3 
23 
No statement - 
& 
4 
7 
Total 
15 
24 
21 
6 
2 
68 
Although theoretically a physician and a nurse are 
responsible for the medical supervision of each child in 
school, there is a lack of coordination and proper liaison 
between the medical and the educational divisions as 
revealed in Tables XVIII, XIX and XX. Regular attend- 
ance upon the cardiac class by the doctor or nurse was 
noted in 14 classes though the frequency of the visits was 
not stated. In 9 other classes, attendance ranged from 
once or twice a week up to once a term. The attendance 
was irregular in 45 classes but it was maintained that 
the physician was available for 21 of these whenever 
summoned (Table XVIII). The number of times the 
school physician was consulted during a term is indicated 
in Table XIX. Forty classes did not employ his services, 
the remainder consulted him infrequently. Similar, in- 
frequent and irregular use was made of the school nurse 
during the term. Incidentally the number of times the 
physician or nurse was consulted represents the impres- 
sions of the teachers and is not derived from any actual 
record of visits. 
74 Frequency of Attendance 
Manhattan 
B’klyn 
Bronx 
Queens 
Richmond 
Total 
Irregular attendance—available when summoned 
6 
6 
6 
3 
21 
Irregular attendance—available only at certain times 
5 
5 
6 
16 
Irregular attendance—not stated if available when called. 
3 
3 
2 
8 
Attend classes regularly—frequency not stated 
7 
3 
2 
2 
14 
Attend classes once or twice per week 
„ 
2 
2 
Attend classes “several times” per month 
„ 
1 
2 
...... 
3 
Attend classes once per month 
1 
1 
Attend classes twice per term 
1 
1 
2 
Attend classes once per term 
1 
— 
1 
Total — 
15 
24 
21 
6 
2 
68 
Number of Times Consulted During Term* 
Manhattan 
B’klyn 
Bronx 
Queens Richmond 
Total 
1-5 times per term 
2 
3 
8 
13 
“Once per week” 
1 
1 
“Once per month” 
1 
1 
“Twice per month” 
2 
2 
Not stated 
2 
6 
...... 
1 
2 
11 
None 
11 
13 
13 
3 
— 
40 
Total - 
15 
24 
21 
6 
2 
68 
* Either during current term or last school term. 
Frequency of Visits to Cardiac Classes by Physicians or Nurses 
Number of Times Physician Was Consulted During Term 
Table XVIII 
Table XIX 
75 Number of Times Consulted During Term* 
Manhattan 
B’klyn 
Bronx 
Queens 
Richmond 
Total 
1-5 times per term _ 
3 
5 
8 
2 
18 
6-10 times per term 
2 
1 
1 
4 
11-20 times per term . . 
2 
2 
“Once per week” 
3 
3 
“Twice per week” 
1 
1 
“Frii]r times per week” 
2 
2 
4 
“Once per month” 
1 
1 
“Rarely” - - - 
2 
2 
“Frequently” 
2 
— 
— 
— 
2 
Not stated 
2 
5 
8 
1 
2 
18 
None during current term 
6 
4 
2 
1 
13 
Total 
15 
24 
21 
6 
2 
68 
* Either during current term or last school term. 
Number of Times School Nurse Was Consulted During Term 
Table XX 
76 Observation of Physicians 
Absentee Problem 
The indifferent handling of the absentee problem revealed 
one of the weaknesses of the cardiac classes. The bus 
driver was stated to be the intermediary between the 
home and the school in one-third of the classes. This 
consigns an important aspect of the problem to rather 
haphazard solution. The routine truant checkups, includ- 
ing cards sent to the home, handle a little over one-third 
of the absences. Home visits by teacher or nurse were 
made infrequently. 
Transportation 
While transportation facilities are often available for 
cardiac children, the summary of information derived 
from physicians’ visits to schools indicated that bus 
schedules frequently serve only to complicate classroom 
arrangements. These schedules were found to be irregu- 
lar and dependent in a large measure on the decision of 
the bus company officials. Children in the same class 
arrive in shifts, some arriving as early as 7:45 A.M. 
Some children do not leave school until 4:45 P.M. 
Instances have been cited in which children were brought 
to school in over-crowded buses by long and devious 
routes. Bus service is not available at times other than 
those stated on the schedule. 
77 Observation of Physicians 
Rest 
The amount of rest for the whole school day was stated 
definitely for 53 classes. The minimum amount was 30 
minutes; in one class it was more than 75 minutes daily. 
The majority of cases varied between % hour to 1% 
hours. The apportionment of the rest time throughout 
the day was not given. 
The rest facilities provided in 58 special classes as shown 
in Table XXI consisted of steamer or other rest chairs. 
Two classes reported that they had cots or beds. Informa- 
tion was lacking concerning the number of chairs or cots 
available for each class. Only one class reported that 
they used the regular school chairs for resting. Children 
had to remove desks and set up chairs for themselves 
in order to rest, inasmuch as personnel is not assigned for 
this duty. Supplementary information from the physi- 
cians’ summary indicates that while children may be 
relieved of gymnasium work and be given extra rest 
periods, they may be asked by the teacher to do errands 
of a nature more strenuous than the exercise from which 
they have been excused. 
Recreation and Play 
No uniformity exists in regard to the provisions made 
for recreation and play; the play periods vary from 15 
to 60 minutes 19 classes had a 30 minute allotment 
(Table XXII). The apportionment of this time through- 
out the day was not specified, although in 53 classes some 
provisions were made. 
78 ERNST P. BOAS, M.D. 
Chairman, New York Heart Association, New York, N. Y. 
Assistant Physician in First Medical Division, Mt. Sinai Hospital, New 
York, N. Y. 
ROBERT L. LEVY, M.D., F.A.C.P. 
Professor of Clinical Medicine, College of Physicians and Surgeons, Colum- 
bia University, New York, N. Y. 
Director, Department of Cardiology and Associate Attending Physician, 
Presbyterian Hospital, New York, N. Y. 
Consulting Cardiologist, French Hospital, New York, N. Y. 
Consulting Cardiologist, White Plains Hospital, White Plains, N. Y. 
Consulting Cardiologist, New York Infirmary for Wojnen and Children, 
New York, N. Y. 
HOMER F. SWIFT, M.D. 
Member, Rockefeller Institute, New York, N. Y. 
Chairman, General Advisory Committee for the Cardiac Program, Depart- 
ment of Health, New York State 
Physicians Consulted by the Committee Type of Rest Facilities 
Manhattan 
B’klyn 
Bronx 
Queens Richmond 
Total 
Facilities available 
Chair (steamer, rest, etc.) 
13 
23 
15 
4 2 
57 
Chairs and cots 
1 
1 
Beds and blankets 
1 
1 
Type not specified 
5 
1 
6 
Rest at desk 
1 
1 
No statement made 
1 
1 
2 
Total 
15 
25 
20 
6 2 
68 
As reported by surveyor. Information was not given 
as to the number of 
chairs, 
cots, etc., available 
for each 
classroom or school. 
Amount Per Day 
Manhattan 
B’klyn 
Bronx 
Queens 
Richmond 
Total 
15 minutes 
1 
6 
1 
8 
20 minutes - 
1 
2 
2 
5 
30 minutes 
6 
6 
5 
2 
19 
45 minutes 
2 
4 
1 
7 
Unspecified 
3 
11 
14 
No recreation or play* 
1 
1 
2 
No statement made 
» 
7 
1 
2 
13 
Total 
*As reported by surveyor. 
15 
24 
21 
6 
2 
68 
Type of Facilities Provided for Rest in Classrooms 
Time Devoted to Recreation and Play 
Table XXI 
Table XXII 
79 Observation of Physicians 
Summary 
It appears from the foregoing that there has been no 
coordination in the care of the cardiac child in school 
and the care of the child given by agencies outside of 
school. It is evident, furthermore, that there has been 
no attempt on the part of the schools to make such a 
correlation nor to use the available materials or facilities 
in any other manner. 
These reports also emphasize the lack of uniformity of 
the care given to cardiac children in the public schools 
of the city; they further reveal that there is no consis- 
tency in the present practices for medical care for these 
children. The entire emphasis of the care of the cardiac 
child in the public schools is seen to be on the physical 
handicap of these heart diseases, as evidenced by special 
rest periods, special attention to activities, provisions 
for transportation and similar physical aids. 
A lack of uniformity exists, even though in the Depart- 
ment of Education there is a special Bureau for the 
Physically Handicapped, which is supposed to initiate, 
and to carry into execution, a plan for the care of cardiac 
children in the public schools. It is evident then, that 
although this problem has been under consideration for 
24 years, a uniform systematized policy of dealing with 
the problem of the care of the cardiac child in the public 
schools has never been developed. 
80 VII 
Summary of Observations by Educators 
AT the time the study was started there were 92 cardiac 
classes in the public schools. A representative sample 
of these classes was selected for study based upon educational, 
economic, sociological and demographic reference statistics 
which were compiled for the Committee. 
Fourteen members of the educational faculties of the 
colleges and universities within the city assisted the educa- 
tional members of the committee and 52 classes were visited 
by this group. 
These specialists made their observations independently 
of each other, and submitted individual reports. Many of the 
reports were supplemented by letters in which the findings 
and opinions of the observers were stated at greater length 
than in the report forms. 
Curriculum 
Teachers of the cardiac classes attempt to hold the curri- 
culum in line as far as possible with that of the regular 
classes. In general, standards of achievement are 
asserted to be the same as for normal children of like age 
and intelligence. 
Increased emphasis is applied to minimum essentials in 
the tool and content subjects with consequent reduction 
in the interpretive, appreciative and integrative phases 
of school studies. The probable explanation of the 
emphasis may be found in the combined operation of 
these factors: (a) the attempt to assist the children in 
meeting grade promotion standards, (b) the emphasis 
on the “tangibles” in such standards; (c) the necessity 
for individual rather than class instruction; and (d) the 
81 Observation of Educators 
reduced time available for instruction. It was maintained 
by many of the teachers that the individualized instruc- 
tion is a significant factor in eliminating special 
pedagogical weaknesses. 
As far as one can judge, the rooms do not generally 
evidence richly developed activity programs. Such special 
subjects as music, drawing, nature study, shop work and 
cooking are reported as eliminated or reduced in 
emphasis. In some cases material from these subjects 
was brought in incidentally in conjunction with the 
industrial arts program or the health projects. The 
probability seems to be that, while touched upon, they 
do not receive the same emphasis as in the regular classes, 
for these subjects had to make way for the great empha- 
sis placed on the fundamental subjects required for grade 
promotion. 
Less strenuous play activities, modified physical training 
and a generally slower physical tempo were reported by 
some visitors to characterize the cardiac classes visited 
by them. 
Increased emphasis on health consciousness, knowledge, 
and routines was found to be almost universally present, 
but the adequacy, appropriateness and effectiveness of 
teachers’ efforts along these lines were frequently ques- 
tioned in the reports. 
In some schools an indefinite type of pre-vocational 
industrial arts program necessitated attendance of 
teachers at frequent conferences with the Inspector of 
Industrial and Placement Work. It appears that the 
implementation of what seemed to be a serious and well 
designed attempt was a function of the individual teacher 
and varied with the emphasis placed on manual activities 
in the particular school in which the class was located. 
82 Observation of Educators 
Daily Program 
The wide grade range within the separate cardiac classes 
necessitate: a daily program markedly different from 
that of regular classes. The predominant type of learning 
activity is individual seat work. Each student is given 
study assignments, usually in traditional textbooks and 
somewhat stereotyped exercise books, and is required 
to recite or submit written papers on his work. 
In some classes older children correct the work of the 
younger ones. The assignments or individual “contracts” 
varied from tasks selected mechanically from a textbook 
to carefully prepared mimeographed “contracts,” de- 
signed for use by all the children in a given grade. As 
noted in connection with the discussion of curricular 
modification, the circumstance of predominantly individ- 
ual work seems to have caused emphasis on the memoriza- 
tion of such items of fact or skill as could readily be 
included in self-study exercise books. 
The pupil’s reaction to the individual assignments varied, 
but was on the whole favorable. The pupils, as a rule, 
worked assiduously and with self-reliance. A cooperative 
atmosphere generally prevailed. Some of the very young 
children seemed somewhat lost, and some of the older 
ones seemed bored. In this regard the hand of the 
particular teacher was apparent. Some of the teachers 
showed remarkable organizing ability; most of them 
seemed highly efficient, a few showed poor management. 
Because of the largely individual nature of the work, 
all sorts of variation in the length of lesson, in the 
distribution of time and in the material stressed were 
reported. It was commonly asserted by the teachers that 
the individual setup resulted in an adaptation to the 
physical and educational status of the pupil. Such ad- 
justments, however, seemed to be made within the frame- 
83 Observation of Educators 
work of a traditional subject-matter approach. Several 
observers commented on an apparent lack of functional 
adaptation to the special needs of the children in these 
classes. 
Regular rest-periods are scheduled, usually ranging from 
45 to 75 minutes daily, and pupils ordinarily bring 
lunches from home, eating them in the regular classrooms 
under rather unsatisfactory conditions. 
Teachers seemed to have a very busy time of it, keeping 
the children profitably occupied. What seemed to make 
it possible for them to cope with this difficult task was 
the breathing spell while the children were occupied with 
their studies. Where the instructional program was 
ineffective in terms of present-day educational thought, 
the explanation seemed to lie in the misdirection of effort 
rather than a lack of it. 
Utilization of Materials and Devices 
Instead of receiving textbooks through the usual channels, 
the cardiac classes are allowed a small fund from which 
the teachers may requisition special text materials. This 
does not always meet the needs, and has to be supple- 
mented with “loans” from the regular school supply and 
the use of sample texts supplied by publishers. A 
considerable diversity of materials appears to be 
employed, including a number of up-to-date instructional 
books and a larger number of the old type of textbook. 
A great variety of teacher-constructed material is used. 
Drill assignments of the busy-work type seems to pre- 
dominate. Some little use of meager reference material 
is sometimes called for in the assignments. There seems 
84 Observation of Educators 
to be no organized provision for the interchange of 
materials among the teachers in these classes. 
As regards maps, charts and other visual aids, the 
cardiac classes seem no better supplied than, if as well 
as, the regular classes. Opportunity to attend school 
movies, to make museum visits, to attend assemblies, etc., 
varied with the school; there was less participation in 
such activities than in regular classes in most of the 
schools visited. 
Individual-Child Requirements 
The teachers in these classes have a fuller knowledge of 
the individual child, as is to be expected from the smaller 
size class, the longer residence with the same teacher, 
and the necessity for keeping physical records. 
Because of the common interest of the teacher and parent 
in the health of the child there is greater parent-teacher 
contact than in the regular classes. 
The teachers are required to maintain a case record of 
each child. This record includes information concerning 
the physical condition, social background and school 
achievement of the child. In a few instances the case 
histories were thorough. In the majority of cases they 
contain only readily available data. Some of the teachers 
report that they have visited the homes of the children, 
but more often knowledge of the home is obtained from 
the child or through the parents who visited the school. 
Children in the special classes were reported to be 
receiving no more complete psychological test service 
than children in regular classes. The “standardized” 
diagnostic tests and the more recently developed diag- 
nostic procedures in school subjects seem seldom to be 
85 Observation of Educators 
used. It was indicated by some of the teachers that they 
were able to ascertain the child’s weakness informally 
and incidentally to the conduct of individual instruction. 
With respect to disciplinary and emotional problems the 
teachers seemed to have grasped something of the ob- 
jective mental hygiene point of view. 
Supervisory Services 
In general it may be said that the teachers in cardiac 
classes receive about the same degree of supervision as 
those in regular classes. To some extent, however, these 
special teachers enjoy somewhat greater freedom of 
action. 
Briefly, the supervisory services include: 
(a) General supervision by the principal, assistant prin- 
cipal, or both. The teachers of special classes are 
expected to follow the usual regulations and attend 
faculty conferences. There is no general rule as to 
the extent to which the special class teacher is per- 
mitted to work out individual problems. 
(b) Special educational supervision by the Inspector of 
Industrial and Placement Work. This supervision 
takes the form of attendance at semi-monthly or 
monthly group conferences. The effect of this super- 
vision is limited by the fact that only one hour a 
week is devoted to handwork. 
(c) Supervisory service, emanating from the office of 
the Assistant Director in Charge of the Division 
of Physically Handicapped Children, appears to be 
sporadic and concerned chiefly with administration 
details. 
86 Observation of Educators 
Age-Grade Progress of Children in Cardiac Classes 
A study was made of the age-grade progress of pupils 
in cardiac classes and a comparison was made with simi- 
lar data compiled by the Bureau of Reference, Research 
and Statistics for the city at large. This showed that 
children in cardiac classes compared unfavorably with 
those in regular classes. The percentages of children 
underage, normal age, and overage for their grades is 
shown in Table XXIII. 
Table XXIII 
Percentage of Children in Cardiac Classes Who Are Underage, 
Normal Age, and Overage for Their Grades, Compared with 
Regular Class Pupils 
Per Cent of Children 
Type Class Underage Normal Age Overage 
Regular Classes 42 44 14 
Cardiac Classes 5 37 58 
These figures are based on cumulative percentages for 
all grades, from the first through the eighth. The 
trends observed at all levels show pronounced retardation, 
but since data were not available for comparing the age- 
grade progress of the children in the cardiac classes with 
their progress previous to their admission to these classes 
and with the progress of other children in the regular 
classes in the same schools, the conclusions which may 
be drawn from these data are limited. 
Age Span and Grade Span of Pupils in Cardiac Classes 
A wide age span and grade span was noted and generally 
commented upon by the members of the committee and 
those assisting it. Data were therefore gathered from all 
cardiac classes in the city on age ranges and grade ranges, 
by means of questionnaires sent to the teachers of these 
87 Observation of Educators 
classes. The distribution of these classes by number of 
half grades taught in them is shown in Table XXIV. 
Table XXIV 
Distribution of Cardiac Classes by Range of 
Half Year Grades in Each 
Grade Range Half Year Grades 
Within Class 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 
Number of Classes 1 1 12 6 11 10 13 13 7 10 4 1 3 0 1 
Total number of classes reporting 92 
Median number of half grades taught in cardiac classes 7 
The difference in the ages of children in the same classes 
ranged from 2 years to 10 years, the median difference 
being 5 years. The segregation of pupils in cardiac 
classes has created classes similar to those of the tradi- 
tional one room country school. The distribution of 
these classes according to the ranges in ages of pupils 
enrolled in them is shown in Table XXV. 
Distribution of Cardiac Classes by Maximum Age 
Differences of Pupils Enrolled in Each Class 
Table XXV 
Maximum Difference in Ages of Pupils 
Number of Years 10 987 654321 
Number of Classes 3- 5 4 15 9 18 21 13 1 0 
Total number of classes reporting 89 
Median age range within class 5 years 
Replies to questionnaires sent to principals of schools in which 
there are special classes for cardiac children. 
The suggestions appearing most frequently in the 
questionnaires returned by principals of schools in which 
cardiac classes are located were the following. 
1. That more adequate medical supervision be provided. 
2. That more adequate information be furnished con- 
cerning the limitations to be placed upon the activities 
of the children in cardiac classes. 
88 Observation of Educators 
3. That the principals be given copies of instructions 
sent to teachers from the Division of Physically 
Handicapped Children. 
4. That the responsibilities of the Division of Physically 
Handicapped Children and of the principals of the 
schools be more clearly defined. 
5. That the allowance for teaching supplies be increased. 
6. That the clerical work now required be simplified. 
7. That there be provided more suitable cots and reclin- 
ing chairs for rest. 
8. That the present transportation service be improved. 
89 Summary and Recommendations 
Summary 
VIII 
THE Board of Education requested the Committee to make 
a thorough study of its present practices in caring for 
and educating pupils with cardiac* diseases and to consider 
the development of a plan of adequate supervision that would 
supplement the educational program for cardiac children 
in the public schools. 
The Committee agreed that, to formulate such a program, 
it would be required: 
(1) To render an opinion as to the medical, nursing 
and social service requirements of the cardiac 
school child. 
(2) To offer diagnostic and prognostic criteria on the 
basis of which the cardiac child may receive an 
education suited to his needs. 
(3) To advise the Board of Education as to the type 
of medical nursing and teaching personnel neces- 
sary for the proper supervision of cardiac school 
children. 
(4) To aid in developing a continuity of care for the 
cardiac children through the coordination of the 
services of agencies in which the public schools 
would serve as an important link. 
(5) To have a complete register of cardiac school 
children. 
The data necessary for the compilation of such a report 
could not be furnished by the Board of Education. The Com- 
mittee, therefore, formulated a plan for securing such 
information, but execution of such an elaborate investigation 
could not be undertaken by practicing physicians. The Board 
of Education was unable to provide the funds with which 
to employ a staff to make this study. 
*The term cardiac includes all children with cardiac diseases and con- 
ditions leading to them; approximately 90% of these children have 
rheumatic heart disease and 10%, congenital. Since the majority of these 
children are rheumatic, particular emphasis is placed on their care. 
91 Summary 
The Chairman personally approached several founda- 
tions without success and most reluctantly abandoned the 
proposed investigations when his efforts failed to secure the 
necessary funds. At the request of the Board of Education 
the Committee agreed to undertake a limited study of the 
present practices in caring for the cardiac school children and 
to make recommendations for improving and extending their 
care. 
The Committee assembled data on 68 cardiac classes. 
Supplementary information was furnished by 44 principals 
of schools having cardiac classes. Information on cardiac 
children in 19 schools without cardiac classes was furnished 
to the Committee by the school medical and nursing services. 
These reports were analyzed and tabulated for the Committee 
by the Statistical Department of the New York Tuberculosis 
and Health Association. 
The criticisms embodied in this report agree in general 
with those noted in previous reports made under the direction 
of the Heart Committee of the New York Tuberculosis and 
Health Association. The opinions expressed are limited by 
the scope of the investigation. 
As a result of the survey, the Committee believes that 
the problem of adequate care for school children with cardiac 
diseases is not fulfilled by the present cardiac classes. Fur- 
thermore, the administration of these classes appears grossly 
incompetent. Among the more significant failures to provide 
adequate coverage for this problem are the following; 
(1) At the present time, only a small percentage of the 
estimated number of children with cardiac diseases 
or conditions leading to them, i.e. rheumatic fever, 
chorea, etc., among the elementary school popula- 
tion is receiving special attention, and such 
facilities are entirely lacking in the secondary 
schools. 
92 Summary 
(2) There are at least 7,000 cardiac and an undeter- 
mined number of potentially cardiac children in 
New York City. The Department of Education 
has been caring for a group of approximately 2,000 
in special segregated classes. The remaining 5,000 
have received no school medical supervision. While 
the Committee feels that cardiac classes should 
be a temporary institution, it would like to go on 
record as recommending that the cardiac child not 
be returned to the regular classes until an adequate 
medical program is provided for him. When such 
a program is developed, the children may then be 
sent to regular classes as rapidly as is consistent 
with their medical condition. 
(3) The cardiac classes have been under the jurisdic- 
tion of the Division of Physically Handicapped 
Children of the Board of Education and the medical 
service has been under the supervision of the 
Department of Health, although the Department 
of Health has not had any authority over the con- 
duct of the classes. 
(4) The assignments of cardiac children to special 
classes are not based upon adequate diagnostic 
criteria. There has been a lack of suitable pro- 
cedures in the management of the cardiac classes 
and the teachers have had inadequate training for 
the management of such classes. Physical arrange- 
ments for rest periods have been poor. The admin- 
istrative difficulties involved in the admission and 
discharge of children to and from segregated 
classes have prevented caring for children on a 
short-term basis. 
(5) There has not been adequate medical and nursing 
supervision for cardiac children who have not been 
in special classes. 
93 Summary 
(6) Procedures* and criteria have been inadequate 
for the proper screening of school children with 
cardiac defects; for a complete diagnosis and 
medical care if necessary; and for suitable adjust- 
ments to their school schedules. 
(7) There has been a lack of interchange of informa- 
tion between the schools and private physicians, 
hospitals, clinics, convalescent homes and social 
agencies concerned with the care of cardiac chil- 
dren. This leads to incomplete and ineffective 
school management and improper handling of 
children. 
(8) There is a lack of attention to the actual educa- 
tional needs of cardiac children with a view to pre- 
paring them for suitable vocations. The number 
of home-teachers is inadequate for the children 
with an acute infection who must remain at home 
in bed for a period of time. The procedures for 
carrying out this home teaching service are slow 
and complicated in the majority of instances. 
(9) The present study, as the one immediately preced- 
ing it in 1934, has not received the cooperation of 
the Assistant Director of the Division of Physically 
Handicapped Children. For example, it was im- 
possible to secure accurate information even as to 
the number and location of the special classes in 
Public Schools. 
in September, 1940, the Department of Health established 
a Cardiac Classification Service to which may be sent by the school 
physicians children suspected of having a cardiac defect. A record of 
the classification, treatment and school program changes recommended 
are entered on the child’s school medical card and the record is marked 
for further follow-up. A copy of the record with an interpretation of 
its significance related to the child’s school program is sent to the prin- 
cipal. This Service is too new to be evaluated fully and it is admittedly 
inadequate in amount. The temporary medical staff will shortly be 
replaced by appointees from the special civil service list for cardiologists. 
It at least represents a beginning wedge toward the establishment of 
a specialized cardiac diagnostic service for school children. 
94 Summary 
It is obvious from the foregoing that there are many- 
gross deficiencies in the present program and that a consid- 
erable number of changes are now not only desirable but 
urgently needed. The nature and size of the problem imposed, 
i.e., the supervision of an estimated 7,000 children, indicates 
that a single special agency should be organized having au- 
thority in both the medical supervisory and educational 
aspects of these cardiac children’s programs. Continued 
divided responsibility will result in perpetuating the present 
type of unsatisfactory supervision and education. To obtain 
efficiency, there should be definite and fixed single responsibil- 
ity stemming from both the Department of Health and Board 
of Education. A rheumatic child’s education and health 
supervision cannot be separated into fixed compartments, 
but must be considered as a unit, because the child is a unit. 
The lack of coordination between the Department of Health 
and the Board of Education and the bureaucratic control of 
the segregated school classes during the past twenty-four 
years has resulted in incompetent care of a relatively small 
percentage of the total number of cardiac children at a cost 
of several hundred thousands of dollars of the public funds, 
and has yielded no definite information on which future 
programs may be based. 
The Committee has concluded that the information and 
data available are inadequate for it to judge whether segrega- 
tion of cardiac children in the public school system could be 
beneficial to them, whether such segregation is necessary, 
or whether they can be adequately cared for in regular classes. 
The cardiac classes which have been set up by the Board of 
Education have failed to produce any evidence which this 
Committee feels justifies their existence. Indeed, as they are 
currently conducted it may well be that children are actually 
being harmed by assignment to these classes. However, the 
Committee does not favor the discontinuance of the cardiac 
classes until an adequate program shall have been developed 
which will insure proper medical supervision for these 
children. 
95 Recommendations 
1. The Committee recommends that the Board of 
Education and the Department of Health make a joint request 
for funds for the purpose of making a study of cardiac chil- 
dren similar to that recently completed by the Commission 
for the Study of Crippled Children. Such a study should 
consider the educational needs of co.rdiac children in relation 
to their physical and medical requirements. 
2. That there be added to the Cardiac Classification 
Service of the Department of Health enough competent 
physicians specially trained in cardiac diseases to: 
(a) Provide classification services for all children 
suspected of having cardiac disease. 
(b) Review all reports from private physicians, 
from cardiac and other clinics, to determine 
whether the diagnoses are acceptable to the 
cardiac classification service. 
(c) Direct children to a proper source for a com- 
petent diagnosis if a satisfactory classification 
has not been obtained, 
(d) Make definite recommendations to the school 
authorities for all cardiac children with respect 
to their school activities based upon diagnoses 
acceptable to them for all children with rheu- 
matic fever or cardiac disease. 
The Committee recommends that the following procedures 
be substituted for those now prevailing: 
3. That as rheumatic fever is frequently found in more 
than one member of the same family, the discovery of a case 
of rheumatic fever in a child be followed by the recommenda- 
tion for the examination of siblings and parents. 
4. That the school health service provide in each school 
where there are cardiac children, the service of a school nurse 
{or other qualified, person) at the beginning of each school 
96 Recommendations 
day, and that all cardiac children previously selected by the 
Cardiac Classification Service be sent to the school medical 
room for inspection to determine whether they appear to be 
in good health and free from upper respiratory infection be- 
fore they are admitted to classes. In the event that no school 
nurse is available for the daily morning inspection of these 
children, the Committee believes that a teacher can be in- 
structed to perform this adequately. It should not take more 
than ten or fifteen minutes daily on the basis of an estimated 
case load of seven cardiac children per 1,000 pupils. 
5. That there be recorded on a suitable form all symp- 
toms of upper respiratory infection, or symptoms of possible 
rheumatic activity, where these are observed, and that these 
children be returned promptly to their homes and their par- 
ents be advised of the symptoms. 
6. That all cardiac children returning to school follow- 
ing an illness be sent to the school medical room for inspection 
to determine their present state of health and the reasons 
for absence. Such children, if necessary, should be examined 
by the Cardiac Classification Service as soon as practicable 
if the reason for absence has a bearing upon the cardiac 
condition. 
7. That cardiac children returning to school following 
acute illness other than rheumatic fever be assigned at the 
discretion of the school physician, for a short period of time, 
to a lightened school program of the type recommended for 
below-par children* 
8. That each cardiac child be given a medical examin- 
ation at least twice a year and that the report forms for these 
examinations provide for recording diagnoses, recommenda- 
tions and plans for future supervision, and that these be made 
a part of the permanent medical records. 
*The Committee for the Study of the Care and Education of Physically 
Handicapped Children in the Public Schools of the City of New York, 
Report on Open Air Classes and the Care of Below-Par Children, Board 
of Education, City of New York, 1941. 
97 Recommendations 
9. That the Cardiac Classification Service provide 
regular supervision of all cardiac children. 
10. That the Cardiac Classification Service recommend 
to the principal and teachers concerned what limitations, if 
any, are to he placed upon the physical activities of each 
cardiac child, such limitations of activity to he in accordance 
with those set forth in the standard classification of the New 
York Heart Association. 
11. That cardiac children with therapeutic classification 
D and E he excluded from public schools. Such children 
shoidd he at home under the care of a physician, in a con- 
valescent home, or in a hospital. 
12. That home-teachers he provided for those children 
whose cardiac condition makes it impossible for them to at- 
tend regular school hut who are able to receive systematic 
instruction for an extended period, and that they he given 
an education suitable to their physical and mental capacities 
and their educational interests. 
13. That an educational program he provided for car- 
diac children who are confined to convalescent homes and 
hospitals in accordance with the recommendations of the 
sub-committee studying the Education of Children in Hospi- 
tals and Convalescent Homes.* 
14. That teachers with acute upper respiratory infec- 
tions should not, during the first three days of their illness, 
come in contact with cardiac children. 
*The Committee for the Study of the Care and Education of Physically 
Handicapped Children in the Public Schools of the City of New York, 
the Education of Children in Hospital and Convalescent Homes, Board 
of Education, City of New York, 1941. 
98 Recommendations 
15. The Committee recognizes the dangers inherent in 
any program of this kind becoming a fixed procedure. It 
therefore recommends that a Medical Advisory Committee he 
appointed to advise the Board of Education regarding the 
medical and educational requirements of the cardiac child in 
school in the light of new discoveries with respect to heart 
disease in children. 
16. Finally, it is recommended that there be kept a 
complete register of all children with rheumatic fever, chorea, 
and rheumatic heart disease. If this is done, the size and 
nature of the problem will he more readily determined and 
the educational, prophylactic and therapeutic problems will 
he more competently envisaged. 
99