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helping to decide whether active rheumatic carditis is present or not present. These
tests usually dapend on heart rate and the variations in heart rate under stress,
and nearly always the observation is of the behaviour of the heart under standard
altering conditions.
It seems that the decision as to the presence or absence of carditis must rest
at present with the clinician who, after a careful review of what history the parent
is capable of giving, uses his eyes and hands and ears and forms an opinion. This
sounds very vague but the considered opinion of an experienced physician is always
positively worth something, whereas a test that is not comprehensive and hence
inaccurate is of negative value.
Apart from the diagnosis of developing valvular disease through repeated examinations
(it is hoped to detect heart disease before the onset of valvular disease if that
is possible), the signs on which the physician bases his opinion in these early cases
are heart rate, position of the apex beat as indicating dilatation but not hypertrophy,
character of the thrust of the heart beat in relation to thickness of the chest wail,
and no more. And it is acknowledged that the heart rate is dependent on subtle
emotional factors, and that the heart may be dilated when a child is examined in
the out-patient department apart from physical disease (even including marked
dilatation, i.e., apex beat one inch and more outside the nipple line). This leaves
very little in the way of definite signs worthy of respect as foundations for an opinion
which may lead to irksome restriction of activity over a long period, and perhaps
to postponement of an important scholarship examination with an effect which is
difficult to calculate on the child's future. It is a sincere attempt to get round this
impasse that leads to the exploration of the well-worn paths of tests of cardiac
function. At this clinic, however, better results are expected from the adoption of
the clinician's standpoint.
Comments on certain physical signs—Systolic murmurs.—Perhaps the commonest
sign for which children are sent to the clinic is a systolic murmur discovered during
routine examination at school. It would not be right to say that all systolic murmurs
should be ignored, for it does undoubtedly occur that occasionally a heart is first
found to be rheumatic because a systolic murmur caught the ear of a doctor and led
to a more detailed investigation. But it would be better for all such murmurs to
be ignored than for all to be taken seriously.
Actually, from the point of view of the seeker after a sign of rheumatic heart
disease, systolic murmurs unless they are heard at the apex and conducted out
need not be taken into account. Such murmurs at the base usually mean nothing,
but when they have significance it is as evidence of congenital malformation and
not of rheumatic disease. Systolic murmurs at the apex are very common in childhood,
and may arise temporarily during illness of whatever nature, and are often
present from early childhood with no rheumatic correlation whatever. Many cases
of loud systolic murmurs at the apex, to a certain extent conducted out, have been
watched from soon after birth onwards, and have been found to have no significance.
The curious thing is that so often the blood should be pumped through such a complicated
series of channels without murmurs.
However, the common residual auscultatory sign of rheumatic carditis is a
systolic murmur at the apex, constant in quality throughout the respiratory cycle,
well conducted out as a rule, and due to mitral regurgitation. Therefore, when this
sign is found the history of the case must be searched for possible rheumatic attacks,
and if it is fairly clear that there has been rheumatic carditis in the past the consequent
liability to carditis in the present and future must be important in determining
treatment. In this way the discovery of a systolic murmur may be valuable. But
a systolic murmur by itself is no argument for or against present active heart
disease.
Palpation of the apex beat.—Palpation of the apex beat is the most fertile