Maxwell, George Morrison

2019-02-15T14:35:29Z

2019-02-15T14:35:29Z

1954

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.

http://hdl.handle.net/1842/35177

The University of Edinburgh

Annexe Thesis Digitisation Project 2019 Block 22

Congenital heart disease in the paediatric age-group

Thesis or Dissertation

Doctoral

MD Doctor of Medicine