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180
Annual Report of the London County Council, 1913
At the final examination all the children presented a notable improvement so far as mental and
physical conditions could be tested, the response to stimuli being in all cases good. There was no
evidence of mental strain. The only outstanding cases of physical strain, apart from those discussed
under the heading of "Heart Conditions," were cases in which there was a dropping of the arch of
the foot. In two cases this was due only to stretching of the leg muscles, in one it was probably due
to relaxation of the ligaments in the case of a girl who had worn ill-fitting boots.
Open air play or work is much less likely to lead to fatigue than similar work or play done in
confined quarters or in a class room. On a school excursion the incidence of fatigue appears to bear
some relation to the clothing worn by the children. Where a minimum of covering is worn the
children, climatic conditions being equal, appear to stand the strain of a long walk much better than
when they are closely covered. The weight of the clothing does not appear to have any great effect;
it is rather the texture that is primarily responsible. The wearing of constricting bands, garters in boys
or tight belts, and stays or corsets in girls, by interfering with the free circulation of the blood
is another cause of fatigue on excursions which can and should be guarded against. The presence
of an actual physical lesion, such as a blistered foot caused by ill-fitting boots, very rapidly engenders
fatigue, even though the amount of work or exercise done is relatively small. The effect of this in
one case, a girl, was very marked; she became slow, inattentive, and tired, although she was doing
the same work, and expending the same energy, as the juniors who showed no signs whatever of
fatigue during the walk.
Taking all these data it is obvious that the majority of the children returned from the
excursion much improved in physique. The improvement in some cases was most marked, while in
others it was not so apparent. In one or two cases there was, apparently, no visible improvement,
although the children, on examination, proved to be much more sensitive to stimuli (see also
observations under Heart conditions). Colour and appearance of the skin were improved in almost
all cases, the change being most marked among the boys.
Conditions of the heart and circulatory system.—Undoubtedly the main point of interest, from
a medical aspect, in regard to these excursions, is the question of cardiac overstrain and its results.
For these reasons Dr. Leipoldt accompanied the children on all their excursions, and took
immediate observations in regard to certain cases, with routine evening examinations on their return
from the walks. This arrangement had the extra advantage that it made him familiar with the
individual conditions of the children, and that it largely obviated the nervousness with which some
children regarded a medical inspection.
At the preliminary examination eight children were found to have slight irregularities in the
condition of the heart, though in no case was there any definite evidence of organic defect. All
these cases were carefully considered, and it was decided that in none of them was there sufficient
reason to exclude the children, since experience in camps has shown that such conditions generally
improve markedly under improved hygienic and open-air conditions. At the same time a note was
made in each case, and it was decided to pay particular attention to these children at the routine
examinations held after each journey.
In all there were 19 children who presented a condition of the heart which might reasonably
be styled as a departure from the normal, though the degree and extent of such abnormality differed
widely in each case, and in no case was grave enough to warrant exclusion of the child from the
party. Seven children whose hearts were normal at the first examination were found on their return
to have a marked increase in the area of cardiac dulness; of these four were cases of normal
hypertrophy after exercise, and two were cases which may justifiably be reckoned as cases of moderate
dilatation. In several other cases in which there was an increase in the area of cardiac dulness before
starting, no further evidence of dilatation or hypertrophy was found on their return.
In two cases a change in the heart sounds was noticed at the routine examinations at Shanklin.
In several cases a soft systolic basal murmur developed after return from an excursion; this in every
case disappeared after a night's rest.
Taking all the cases and studying them in relation to the response of the children's hearts on
the actual excursions, in two cases only was there marked evidence of cardiac dilatation, and both
were in children who were obviously weak. In the one case the child ought not to have accompanied
the party, and in the other something more might have been done to guard against overloading the
stomach and engendering fatigue. In this latter case no blame could possibly attach to the teachers
or those in charge of the party, since at the preliminary examination the child's heart was noted as
normal and no extra precautions were suggested. When it was found that he stood the strain badly
every precaution was taken to prevent undue fatigue and overstrain.
Increase in the area of cardiac dulness was found to be more common in the boys than in
the girls, although the "official" work done by both was identical in severity and character. The
reason for this is probably because the boys managed to get through a vast amount of extra and
entirely "unofficial" work in the shape of romps on the beach or on the walks, and in this manner
threw a much greater strain upon their hearts and muscles. It is difficult, if not impossible, to guard
against such extra exertion without unduly limiting the liberty of the children and restricting the
amount of enjoyment they contrive to get out of the excursions. A careful "leader" will, however,
use his discretion to check undue enthusiasm on the part of the children, especialty on the return
journey, and above all in the evenings after meals. The absence of any evidence of severe cardiac
overstrain on this journey must be ascribed largely to the excellent supervision of the leaders and to
the discipline maintained indoors, especially in regard to retiring at night.
While it is impossible by any preliminary examination and in the absence of medical supervision
on the journey itself, to eliminate all chance of overstrain—since a child whose heart appears
normal may respond badly to the strain, while one whose heart appears weak may respond well and
derive great benefit from the regular walks—it must always be the duty of the leaders to pay