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181
Report of the County Medical Officer—Education.
particular and individual attention to children who are found to be suffering from slight breathlessness
after ascending an incline at the normal rate of progression.
It cannot too strongly be urged that every form of exercise entails a certain amount of strain
upon the child's heart, but it must also be pointed out that in a child this organ is very quickly
responsive to all calls made upon it and adapts itself readily to altered conditions. Too much has
probably been made of cardiac overstrain in children, and it is possible to take too grave a view of
the alterations in the evidences yielded by ordinary clinical examination of the heart in children who
have been subjected to physical strain. Making allowances for the difficulties and inexactitudes in
limiting the area of cardiac dulness by percussion, it may be granted that an increase in such dulaess
is apparent in GO per cent, of children who have undergone a more or less severe physical strain, or
at least an unaccustomed physical strain, for several days, but such increase seems to be perfectly
natural and harmless and on a par with the increase in the development of the calf muscles and the
chest expansion which almost always accompanies it. It is, in fact, a physiological use hypertrophy,
and cannot honestly be regarded as evidence of cardiac dilatation unless it is accompanied by other
evidences of such weakening such as feeble pulse, irregularity, a fall in. the blood pressure, and the
presence of cardiac murmurs. The observations made on this journey support this view and show
very clearly that real dilatation is to be met with only in children who have also other signs to show
that they have been exposed to too severe a strain which has harmed other organs besides the heart.
Orthopœdic Conditions.—A few cases of slight lateral curvature were noticed at the preliminary
examination. There was no change in these at the final inspection, although the general condition of
these children had improved. The cases of flat feet have already been referred to. It may be added
that the one case, in which the sinking of the arch was marked, could scarcely be said to have been
directly due to the walks. Flat foot is caused more by standing than by walking, since the standing
attitude tires one group of muscles which in consequence relax, while walking exercises both groups.
Where marked flat foot is the result of walking strain it is invariably due to ill fitting boots and sore
feet, as it was in this case; a much rarer cause is fracture of the metatarsals, brought about by suddenly
bringing down the foot on a hard road while the leg muscles are relaxed. This is not uncommon in
soldiers on a march who have been walking at ease, and are suddenly called to attention, but is hardly
likely to happen in the case of children, since the fracture is one by muscular violence. In the case
of marked swelling and soreness of the feet after a long walk it is, however, well to examine the
injured foot to exclude such an accident since permanent flat foot results if the lesion remains
untreated.
Summary of Conclusions.—After careful study of all these children, and a consideration of the
data elicited before and after the trip, it is possible to summarise all the available conclusions in a few
paragraphs.
(1) All the children benefited in some way from the change and the holiday, some,
however, much more than others. The increase in weight and height was greater than
recorded on other short trips of a similar nature by English or Continental observers.
(2) Provided proper care is taken in supervising the children and in grading the
amount of work done, there is no reason to conclude that children, who are not quite normal
and up to the usual physical standard, are harmed by taking part in a short trip of this
kind. On the contrary there is distinct evidence that such a holiday conduces to their
improvement.
(3) The age limit of children allowed to participate in such a journey should not,
except in very exceptional circumstances, be below eight years. Younger children are
an inconvenience, and their proper care and supervision require much greater individual
exertion on the part of those in charge. In addition they hamper the party in every way,
and the evidence tends to show that the amount of benefit they derive from such a short
trip is less in comparison with that gained by older pupils.
(4) Fatigue is best guarded against by attention to such responsible factors as clothing,
footgear, sleep, and intestinal sepsis due to constipation. There is no reason to deprive
the children of mental work, provided that due care is taken to attend to these factors.
(5) Children with slight bronchial catarrh and "functional" cardiac conditions need
not be excluded, as they undoubtedly benefit from the journey. Their selection, however,
entails some care and discrimination, and when they are allowed to go, special attention
should be given to them on the journey.
(6) Greater stress should be laid on the importance of insisting on an adequate amount
of sleep, the minimum of which should be nine and a half hours. Longer periods should be
allowed for on occasions when the following day's excursion involves extra physical effort.
(7) Similarly, stress should be laid on the importance of regular and proper evacuation
of the natural reservoirs, and every facility should be afforded to the children to attend to
these matters of personal hygiene. A preliminary lecture by the teachers responsible is,
perhaps, the best way of bringing home to the children the importance of this matter. Care
should be taken that the diet given includes a reasonable amount of peristaltic stimulant in
the form of cellular fibre, or fruit juice.
(8) The gravity of incurring cardiac strain is undoubtedly great in children who are
feeble and ill-nourished, but has been magnified out of all proportion to the reality. An
increase in the area of cardiac dullness when the child returns is common and harmless; for
purposes of comparison the heart sounds, the blood pressure, and the rate of the pulse are
better guides than the evidence yielded by percussion.
(9) It is highly desirable that a final inspection of the children should be made by the
doctor or nurse at least 48 hours before the party leaves for its destination, so as to exclude
children who may have developed defects which have not been noticed at the ordinary
preliminary inspections. This is especially desirable in regard to skin diseases.