The effect upon the heart's substance of the morbid changes in the valves is much the same in the child as in the adult. Hypertrophy and dilatation follow, and in severe cases may reach an extreme degree. In the young subject there is great power of compensation ; and we often find that the vigour of the heart becomes rapidly increased so as to make up for the valvular deficiency, and the health of the child is seemingly un impaired. In examining the heart in early life we must not make the mistake of attributing all murmurs to valvular imperfection—that is to say, to a degree of imperfection injurious to health. It is more common in the child than in the adult to find a systolic murmur at the apex of the heart, without any other sign of regurgitation through the auriculo-ven tricular opening. Such a murmur may persist for years, and finally disap pear without having led to any alteration in the site of the apex beat, or other indication of ventricular hypertrophy. In such cases there is prob ably some roughening of the surface of the valve, which, however, still re mains perfectly competent to perform its functions.
Symptoms.—A valvular lesion of the heart does not necessarily give rise to symptoms of discomfort ; and it seems that in some children years can pass without any sign of distress being manifested on account of the cardiac mischief. It is common to find signs of valvular insufficiency in a child who has been brought for advice on account of some casual derange ment quite unconnected with the condition of the heart ; and even in cases where breathlessness has been noticed, it is often a recent symptom, while the enlargement of the organ indicates that the valvular lesion is of much more remote origin. When regurgitation is slight, the increase of power quickly acquired by the heart compensates completely for the de fect, and no unfavourable symptoms are noticed until dilatation occurs, or a new attack of endocarditis aggravates the original imperfection.
Usually, the earliest and by far the most commonly present symptom is breathlessness. It is noticed that when the child plays at any boisterous game, he becomes very pale, and pants in an unusual manner. If very pro nounced, the symptom may be accompanied by some lividity of the lips, and pain about the chest. In advanced cases, where much dilatation has ensued, orthopncea may be present, and is a symptom of great gravity ; and some times attacks of syncope are noticed. Palpitation is complained of in child hood less commonly than in adult life ; but if the patient be anemic, the heart's action may be tumultuous on slight exertion. Ancemia is a fre quent consequence of the more aggravated forms of cardiac lesion. As in
the adult, it is usually present if there be insufficiency of the aortic valves ; but even in this case it may not be noticeable as long as the child is kept quiet. A little girl lately under my care, with aortic and mitral regurgi tation, always had a good colour as long as she remained in the hospital ; indeed, the healthiness of her complexion was the subject of remark by those who were acquainted with the serious lesion under which she was labouring.
Ilmmorrhages sometimes occur. The nose may bleed repeatedly ; and in older children humoptysis may be seen, especially if there be mitral stenosis as well as regurgitation. A little girl, aged twelve years, with mitral obstructive and regurgitant disease and great hypertrophy of both ventricles, frequently expectorated blood. The symptom would be prob ably met with more frequently were it not for the childish habit of swal lowing all sputa brought up from the lungs. Another common conse quence of • the pulmonary congestion induced by the valvular lesion and the resulting tendency to catarrh, is cough. This is usually short and hack ing ; but if loose, for the reason stated is rarely accompanied by expectora tion. When dilatation of the heart occurs, oedema follows quickly, and the disease then presents the same distressing features which are so familiar to every one in the case of the adult.
An occasional accident is embolism. This is sometimes the conse quence of ulcerative endocarditis, disintegrating particles of an infective organic matter being carried off into the circulation and deposited in va rious organs, where they produce the consequences known to follow the presence of such infarcts. This complication, which is accompanied by high temperature and symptoms of blood contamination, has been already referred to (see page 158). It appears, however, that an ulcerative process is not necessary to the separation of portions of fibrinous matter from the valves. We occasionally meet with cases where a child, the subject of re cognised heart lesion, but making no complaint and appearing to be little troubled by his infirmity, suddenly becomes paralysed on one side from obstruction of the middle cerebral artery. The symptoms which accom pany the onset of the paralysis vary. The child may vomit repeatedly ; or be seized by convulsions followed by unconsciousness ; or pass into a state of delirium or even violent excitement. Sometimes the embolism takes place more quietly ; and nothing is noticed until it is found that the child's face is drawn, and that one side of the body has lost its power.