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78
on account of their acute nature scarcely come under the purview of the school
doctor.
The main object of the investigation was to ascertain the early signs of cardiac
implication. A frank history of rheumatism in any of its variations should mark
out that child for special and repeated examination. The appearance of the child
is important—whether pale, apathetic and off his food, easily fatigued, occasional
rises of temperature, fleeting erythematoid rashes, indefinite pains and aches,
hypersesthetic patches on the skin, clubbing of finger tips, enlarged and tender
spleen, etc. The myocardium is early involved and so there is an alteration of the
first sound, usually a lengthening and roughening, the pitch and intensity is lowered,
sometimes followed by a variable systolic murmur—this early myocarditis results
in a lowering of the power of the muscle which is compensated by an increase in
cardiac rate—so that a child with a clear rheumatic history, with an altered cardiac
"tone" and a persisting rate of over 100, unaltered by lying down and markedly
increased by exercise and not coming down to the pre-exercise rate after 2 minutes
rest, requires careful and repeated examination. Functional tachycardias, common
in nervous children, as is also adolescent irregularity (sinus arrhythmia), alter the
pulse rate on lying down or on resting for a few minutes.
The exercise adopted in children under 12 was hopping 4 or 5 inches from
the ground 20 times on each foot and in those over 12 stepping up and down the
seat of an ordinary chair 20 times—the pulse rate being taken before the exercise,
immediately after and again 2 minutes after ceasing the exercise. This exercise
is a useful guide to the present efficiency of the heart and also forms a necessary
guide for future reference.
Many children do not present definite valvular disease until after school life,
until in fact the damaged valves have had time to undergo fibrosis, and so it is
well to search for the early cases and get them under the necessary treatment.
Uncomplicated systolic murmurs do not usually call for much anxiety;
diastolic murmurs are invariably serious and thrills are only present in affected
hearts; enlargement is always a sign of structural alteration.
So far as congenital abnormalities are concerned, if the heart had been able
to carry on its work through the period of "greatest momentum of growth," without
retarding the physical development and without producing any of the signs of
inefficiency, then the presence of such abnormality is in all likelihood not serious,
but on the other hand, if stunting of growth is present, dyspncea, pallor or cyanosis,
venous pulsation with enlarged liver, congestion of the bases of the lungs or other
signs of an embarrassed heart, then in all probability this child will not attain
adult age."
Dr. McVail's
observations
on children
prematurely
born.
Dr. Elizabeth M. McVail has followed up the school history of children with
a history obtained from the mothers of premature birth. Out of 1,306 births of
which particulars were obtained, 65, or approximately 5 per cent., were premature,
23 of the children died under the age of one, giving a mortality very similar to that
recorded for London in the Registrar-General's returns. No survival was recorded
of children born at 6 months, 12 out of 23 died who were born at the 7th month,
and 9 out of 40 born at the 8th month. In addition 5 children died after the first
year and before school age, and one child died after arriving at school age.
Although the infant mortality of the 7th month babies is more than twice that
of the 8th month babies, Dr. McVail found upon examination, at school, of 56 children
who had been prematurely born, that there was no appreciable difference in physique
between children born at 7 months and those born at 8 months. Physical measurements
were taken in all cases. The general conclusion she has been able to arrive
at is that premature children require greater care not only during early, but also in
later, infancy, but that if they survive to school age there is no very great deviation
from the normal in regard either to risk of death or to general physique. Of