Symptoms.--The physical signs depend upon the seat of the lesion, its effect on the circulation and cardiac muscle and the manner in which the rnyocardium reacts, and are on the whole concealed by symptoms well known from the pathology of later life.
Some peculiarities in the auscultation of children should be men tioned. The murmurs of valvular heart lesions in children are usually very land. In childhood, in contrast to later periods of life, it is very exceptional for a serious lesion to run its course without apparent mur murs. Besides, cardiac murmurs in children have as a rule two points of maximum intensity, one upon the anterior chest wall corresponding to the seat of the valvular lesion and the other in the back, to the left or right of the vertebral column (see also p. 455). In small children with decided cardiac hypertrophy the murmur is not rarely transmitted to the sacrum or to the head and extremities.
When cardiac lesions are combined in childhood, an excessive increase in the size of the heart very frequently develops, with increase in its cavities (cor bovinum). In such cases a marked forward arching of the left side of the heart occurs, with an intense vibration in all the intercostal spaces, a forceful. very diffuse apex-beat and not rarely a very enormous area of heart dulness. As a rule, then, the heart occu pies a more horizontal position, with the right ventricle, in its large circumference, lying directly, against the diaphragm. An epigastric or abdominal pulsation is visible from a distance. In such conditions the heart murmurs are also heard in the epigastrium and over the entire abdomen. Radioscopic examination best shows the relations of the heart and its separate parts in position and size.
Several physical signs which are frequent and of special importance in the heart lesions of adults are rare in childhood and of less significance. Among these is arrhythmia, which may constantly be absent absolutely in serious fatal cardiac lesions of childhood; which is, however, more frequently; found in children whose hearts are unaffected. Accentua tion and a metallic quality of the second sound at the aortic area is very rare in cardiac lesions of children; on the other hand an accentuation of the second sound at the pulmonary area is mom frequent with hyper trophy of the right side of the beart. Reduplication of the second sound at the base of the heart, more frequently found in mitral stenosis of adults, has no significance in early childhood.
True venous pulse, dropsy and decided hypertrophy of the visceral organs from congestion are rare in early childhood, as a result of the extraordinarily strong compensatory apparatus of the car diac musculature (see p. 452).
As regards the junctional symp toms of acquired heart lesions in chil dren, stress should be laid upon the extraordinary subjective tolerance of children. Alost cardiac lesions in chil dren persist until puberty with good compensation, and especially the years before the child goes to school are very free front subjective disturbances on the part of the diseased heart. Fre quently loss of compensation, with all its well-known functional injuries, first appears at the age of puberty, simul taneously with more intense mental demands upon the children. IIere the favorable relation between the width of the blood vessels and the heart, already mentioned on page 452, has become shifted, to the detri ment of the heart.
According to Ferret's statistics, 21 per cent. of acquired heart lesions of children were free from subjective symptoms; 21 per cent. showed slight functional disturbances and 42 per cent. had moderate or severe symptoms of loss of compensation. Almost one half of the cases in childhood run their course without subjective symptoms.
Cardiac lesions are, on the whole, better borne during childhood than in later life. The most essential subjective disturbances are dysp ncea, palpitation and a tendency to bronchial catarrh. Apart front the rare syphilitic affection of the heart, stenocardial attacks are not observed in childhood because of the absence of arteriosclerosis.
Often children with acquired heart lesions show a peculiar cachexia, which Germain See has correctly described as the chlorotic form of juvenile cardiac lesion. The children are strikingly pale and wan, like young girls with chlorosis, suffer from headache and dyspepsia; are. short of breath, indolent, very capricious and irritable and show a slight cyanotic discoloration of the mucous membrane. According to Hoch singer's experience children ;with cor bovinum are of this type very constantly. Striking changes in the relations between white and red blood corpuscles are lacking in chronic acquired heart lesions of child hood, in contrast to the congenital lesions.