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tions, rheumatic fever and rheumatic heart disease present problems that can be met only if many skills and resources in addition to the strictly medical techniques are utilized. If a child has rheumatic fever it is obvious that considerable adjustment of his whole pattern of living, and that of his family as well, may be necessary if he is to accept and benefit fully from the prescribed medical treatment, which usually includes a long period of rest in bed. Frequently a great deal of help must be given him to attain the desired end. It is perhaps not so obvious but it is equally true that the provision of diagnostic services is not an exclusively medical problem. Indeed the determination of the correct diagnosis for a child with a heart murmur or with vague aches and pains is a very difficult technical medical problem, and to meet it the physician needs experience in the care of children, sick and healthy, as well as experience in cardiology and in the interpretation of laboratory procedures. There are, however, many other aspects to the provision of diagnostic services. Let us look at some of the aspects that come to the attention of the State crippled children's agencies providing services to children with rheumatic fever or heart disease.

First of all, a good history of the child and his family is essential. It may be important to know whether other members of the family have had rheumatic fever, whether the child was once a "blue baby," whether the family situation might lead the child to seek attention through complaining of aches and pains,

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whether the child might wish to stay home because he does not like school, whether, if the child presents symptoms of acute disease, he has been exposed to other diseases which are sometimes confused with rheumatic fever-such as undulant fever, or tuberculosis. The parents may know and may give the answers to these questions, but often outside help in getting the answers is badly needed. The State agencies have called for help from the family physician, the hospital and clinic records, the medicalsocial worker, the public-health nurse, the epidemiologist, the school physician, the school teacher, the social agency, and other sources.

Now the clinician makes his diagnosis on the basis of the history, the physical examination, and the laboratory findings. But the matter is far from ended at that point. The child and his family must accept and act on the diagnosis, and so must all the individuals and agencies that have to do with the child. Suppose the child is found to have active rheumatic fever; care must be given him in a hospital or a sanatorium or a convalescent home or his own home. The State rheumatic-fever program will provide the necessary care, but the child and the parent must be willing to participate in the plan of treatment. We all know how difficult it is for any one of us to make up his mind that he is sick enough to take a week or so off and go to bed, especially in a hospital. How much more difficult it is to look forward to many months of rest in bed! Careful explanation is given by the physician but this may not be enough. The medical-social worker or the pub

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lic-health nurse or someone else in whom the parents have confidence, such as the priest, may be called on to help interpret the situation to the family.

Or suppose the child is found to have minimal rheumatic heart disease with no active rheumatic infection at the time of examination. The usual reaction of the parent and the child to this diagnosis is undue anxiety about the heart disease and at the same time not enough concern about the possible recurrence of rheumatic fever. The diagnosis must be carefully interpreted therefore to the child and his family, so that they will understand clearly that the child should be encouraged to lead an active life, restricted by his own limits of fatigue rather than any arbitrary amount of exercise. They must at the same time understand the urgent need for keeping the child under medical supervision, maintaining his general health at the highest possible level through satisfactory diet, appropriate clothing, decent housing, good health habits, and avoidance of exposure to infection, particularly infection of the upper respiratory tract.

The diagnosis must also be interpreted to the public-health nurse who is to help supervise the child's health and hygiene. It must be interpreted, too, to the social agency agency that may be called upon to help the family improve its housing or its food budget. One State medicalsocial worker, on the basis of a study of the diets of several rheumatic children whose families have been receiving public assistance, has interested the State department of welfare in studying the whole question of whether the present assistance budget is enough to provide an adequate diet.

The diagnosis must be interpreted to the school teacher, the school nurse, the playground supervisor, and the school physician so that they will realize, for example, that walking up steps is usually not harmful to a rheumatic child, but that an epidemic of colds in the schoolroom is extremely dangerous for him. This interpretation may also have to be taken to the department of education in an effort to get rid of certain policies and procedures which make it difficult to control epidemics of upper

respiratory infections in schools. We know that, in some States, funds for individual schools are granted on the basis of pupil-days' attendance and this has created a general tendency among the teachers in such States to discourage children from staying home from school on account of colds. If children are to be protected against school epidemics of upper respiratory infections, policies such as this in the school system must be brought to light and steps taken to change them.

In at least one State the significance of the diagnosis was explained to the secretary of the local housing agency in an effort to get better housing for the families of rheumatic children.

Now, suppose the child is found to have no heart disease and no rheumatic fever. That, you might think, would be an easy diagnosis to interpret. The State agencies, however, have not found it to be so easy. Not infrequently a diagnosis of heart disease has previously been made by the family physician who is going to continue giving medical care to the child and his family. In one State an expert diagnostician was sent into a small town in which an epidemic of rheumatic fever had been reported by the local physician. The State consultant found that nine children who had been kept in bed for several months to a year actually had no rheumatic heart disease and showed no evidence of ever having had rheumatic fever. That was a ticklish situation, but the consultant handled it so well that the children were restored to normal living habits with the consent and understanding of the local physician. In another State about 25 percent of the children who were sent to the diagnostic clinic by local physicians had been told previously that they had heart disease. In that State every effort was made to persuade the local physicians to come to the clinic with their patients. Thus the conflicts in diagnosis were handled quite informally with the local physicians, who learned a good deal about the diagnosis of heart disease.

Besides the problem of explaining the diagnosis to the physician the problem of getting the child and the family to relinquish a previous diagnosis of heart disease is sometimes difficult to solve. Some families and some children are