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REPORT ON THE WORK OP THE PAEDIATRIC CLINIC
by
E.Hlnden, M.D.M.R.C.P.
The work of the West Ham School Health Consultative Clinics has continued to follow
the pattern laid down in previous years. The decline in numbers, noted previously, has
continued: probably some of that, at least, is due to the fall in the birth-rate from the
peak of the immediate post-war years. It is possible that the figures will increase again
with the recent rise in the birth-rate.
One of the difficult diagnostic problems that is continually presenting itself at
school health examinations, is the symptomless systolic murmur. Until a few years ago,
the doctor was concerned lest he might miss a sufferer from a rheumatic heart disease.
This is now much rarer than it was, and most doctors are on the lookout for it; so that
the true "missed case" of rheumatic fever, revealing itself only later by the murmur of
organic valvular disease, hardly exists. Nowadays the differential diagnosis is quite
other - it is from congenital heart disease.
The enormous advances made in cardiac surgery have focussed attention on this group
of diseases, for many of them are now treatable, and at the present rate of development, It
almost looks as though hardly any defect will remain outside the scope of surgery. Operations
on the great vessels outside the heart, such as tying a persistent ductus arteriosus, or
exercising an aortic stenosis, have now attained "classical" status. The newer operations
for repairing septal defects in atria or ventricles involve stopping the circulation and
Widely opening the chambers of the heart, oxygenation either being maintained by an extracorporeal
machine or else rendered unnecessary by artificial hibernation. These manoeuvres
are by no means routine: they involve a number of highly skilled and trained physicians
and surgeons working together as a team, and special apparatus; but there is no doubt
that the techniques will be simplified in time, and that more and more centres will start
to do them. One most important point which has emerged from all this, is that if operation
is to be successful, it must be undertaken before the strain of the abnormal circulation
through the heart has brought about irreversible anatomical change.
This brings me back to the diagnostic problem I mentioned: faced with a murmur in
a child who shows no symptoms whatever, the doctor has to decide whether the murmur is not
due to congenital disease and so may be ignored, or whether it is indeed caused by a defect
which has not yet produced symptoms, but which may well do so if not taken in hand and
treated: the danger being that when it does become manifest, it may then be too late for
remedy. Decision is not easy, and will usually call for x-ray examination and electrocardiography;
at times further techniques such as angiography and cardiac catheterisation
will be required.
Even with this newer knowledge at our disposal, it should still be borne in mind
that the majority of systolic murmurs picked up on routine examination in healthy children,
are without significance; and of course it is extremely important to tell the anxious
parents so, at the first opportunity.
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