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Chronic Valvular Disease of the Heart

signs, common, lesion, rheumatism, life, child and adult

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CHRONIC VALVULAR DISEASE OF THE HEART.' lisease of the heart is very common in childhood ; and there are few forms of valvular lesion found in the adult which may not be also met with in the young subject. The signs and symptoms to which such faulty conditions give rise are much the same at all ages. A child, like an adult, may have valvular disease without himself being conscious of discomfort or betraying to others any sign of inconvenience ; or he may suffer from breathlessness, palpitation, general oedema, and all the other symptoms which are liable to arise in an older person similarly affected. The physi cal signs of valvular lesion, and of consequent alteration in size of the organ, also resemble very closely those met with in adult life. It is not therefore, necessary to enter into these subjects at great length. It will be sufficient to point out any peculiarities of feature conferred upon the cardiac disease in the child by the youthful age of the patient.

Causation.—Amongst the causes of valvular defect of the heart, rheuma tism takes by far the most important place. To this disease, indeed, most of the cases of heart disease occurring in early life are to be attributed. The manifestations of rheumatism in the child, as is stated elsewhere, are often very trifling ;- and in infancy, on account of the difficulty of referring signs of distress to their true source, the disease no doubt,. often escapes detection altogether. Next to rheumatism, scarlatina is perhaps the most common cause of endocardial inflammation. This disease is often followed by joint pains and other symptoms indistinguishable from rheumatism ; and chronic valvular disease of the heart appears in not a few cases to owe its origin to this exanthem. According to Bouillaucl, measles is also an occa sional precursor of endocarditis ; and Dr. Samson has recorded a case in which both pericarditis and endocarditis occurred a fortnight after con valescence from measles had begun. This fever, however, is no doubt a much less common cause of the valvular disease than the other maladies which have been mentioned. In certain cases, chorea appears to be a start in 6 0. point for mischief. Sometimes, without any evidence of rheu matism, we find a murmur become developed in the course of the choreic attack ; and it may happen that the morbid sound continues after the ces sation of the nervous derangement, and is accompanied after a time by displacement of the heart's apex and other signs of hypertrophy. Still, in

these and other cases where no history of rheumatism is to be obtained, it is possible that the endocardial lesion may still have a rheumatic origin. The tendency of this disease is to attack the fibrous tissues of the body generally ; but all need not suffer at the same time. The selection, even, of the joints to be affected by the disease is apparently capricious. Some are attacked while others are passed over. It is surely, therefore, not unreason able to suppose that the fibrous tissues of the heart may be implicated while those of the joints are left unharmed. In addition to the preceding, syphilis may be an occasional cause of the heart lesion, for valvular imper fection is sometimes found in very young infants, the subjects of inherited syphilis.

Atheromatous degenerations, which are so common a cause of valvular lesion in the adult, rarely occur in early life. It once, however, happened to me to meet with a small calcareous mass on one of the aortic valves in a little girl three years old. The mass had given rise during life to a, systolic murmur which was most intense at the base of the heart, but could be heard distinctly at all parts of the chest. This child had never had rheumatism, as far as could be discovered, but had suffered from measles nearly two years previously.

Rickets has been said to be a cause of hypertrophy of the heart ; but I cannot say that I have ever myself met with a case of cardiac enlargement which I was able to attribute to the chest distortion produced by this dis ease. When the framework of the thorax is much deformed, the heart is, no doubt, forced more forwards towards the wall of the chest, and a larger area of impulse is consequently perceptible. It is common in such cases to be able to feel the contractions of the right ventricle in the epigastrium ; but this sign alone is insufficient proof of enlargement of the right side of the heart in the absence of extension of dulness to the right of the sternum, and other necessary signs of that condition.

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