A large number of congenital anomalies of the
heart are presented and discussed. All of the cases
were within the paediatric age- group, the majority
being less than five years of age. The symptoms and
signs are discussed in detail, and the results of
electro- cardiography and X -ray investigation presented.
The results of cardiac catheterization are given in
certain cases. The diagnosis was tested by each or all
of these methods, and, too often by autopsy. Further
proof has accrued since the completion of the thesis
and no undue reversal of opinion has ensued.
In the intervening time also, further information
concerning the general attitude towards these cases has
been obtained. It is essential that each case should
be fully investigated at the first appearance of the
child in thè out -patient department; too often the
child is left "until it is bigger ", or "until it is in
trouble ", before every avenue is explored. The author
unfortunately shared this attitude, until the frequency
of death during the "follow up" period showed how lethal
this neglect could be. Potentially curable cases such
as atypical patent ductus arteriosus were found at
autopsy, because retrograde angiography or cardiac
catheterization was not carried out in time.
Similarly operation should not be denied the
youngest of children who have such lesions as tetralogy
of Fallot or pulmonary stenosis with a normal aortic
root. Such cases too often die while waiting for the
"great vessels to increase in size ". The indication
for operation are the classic ones of paroxysmal dyspnoea, and limitation of effort; to these must be
added failure of growth, epitomized by a sinister downward progress of percentiles. These and more subtle
signs of '!failure to thrive ", are best appreciated by
those with a paediatric rather than a cardiological
training.
Even if mistakes are made, thoracotomy in
experienced hands will be safe enough to allow of
direct examination of the lesion, if pre- operative
assessment is incomplete. Undoubtedly the attendance
of personnel with physiological apparatus for the measurement of pressure and oxygen tension will increase the
efficiency of the surgeon and may lead to the discovery
of better methods of treatment.
So then it is suggested that every child who shows
symptoms be considered as potentially operable. Thus
all cyanotic cases should have angiocardiography if the
diagnosis is not immediately obvious. Equally, cardiac
catheterization should be carried out in allacyanotic
cases with symptoms unless a "Gibsori' murmur, absent
femoral pulses, or other undoubted criteria make the diagnosis reasonably absolute. The latter technique
is, as the author has found, perfectly applicable to
all cases, except perhaps premature infants - in one
case an infant of 4 Kgms. was subjected to this investigation - with the happiest results.
The high morbidity and mortality in these children
is a challenge to the therapeutic acumen of the
paediatrician, and demand his constant review and supervision of the individual case. Fluoroscopy and interpretation of the electrocardiogram should be within the
province of the paediatric physician, and, if the
apparatus is available he should be able to turn his
hand to cardiac catheterization.
