A little girl, aged six years, had been subject for sixteen months to shortness of breath after any exertion, and at such times to blueness of the lips. She had never been known to have rheumatism ; but, six months before her admission to the hospital, had had an attack of measles, which had been followed by whooping-cough. There was a suspicious history pointing to syphilis, and the child was being treated by one of my surgical colleagues for keratitis. Her temperature was normal.
On May 10th, the patient was noticed to be dull and apparently sulky. She passed her urine and feces once involuntarily, which she had never done before ; and her temperature on that evening was 99.6°. On the next morning the mercury registered 99.4°, and the child's mouth was noticed to be drawn to the left side ; she could not stand ; her right arm was completely useless ; and her right eye closed imperfectly. In addition, she was aphasic. Although drowsy, she could be easily roused, and she took her food well, having no difficulty in swallowing.
On examination of the heart, a loud systolic murmur was heard all over the front of the chest, and also at the back ; but it was louder on the left side, posteriorly, than on the right. In the left axillary region it was well beard, but became greatly diminished in intensity at the posterior axillary line. In front, the pitch of the murmur was highest at the base of the heart, and fell perceptibly towards the left nipple ; but in intensity of sound there was little difference between the nipple and the upper part of the sternum.' The point of maximum intensity appeared to be the pulmonary valves. The apex beat was in the fifth interspace in the nipple line, and the right border reached nearly a finger's breadth beyond the right margin of the sternum. There was no clubbing of the fingers nor any signs of cya nosis, at lea!st while the child was at rest. That evening (May 11th) the temperature was 101.4°.
On May 12th (the second day of the paralysis), the temperature was 101.6° at 8 A.m., and rose in the evening to 103.8°. The incontinence of urine still continued, and the paralysis and aphasia remained the same. The child was perfectly conscious and intelligent, and tried in vain to speak. Her tongue, when protruded, deviated to the right side ; the right arm and leg were perfectly flaccid, and their sensibility was diminished.
The muscles responded well to the interrupted current. The temperature fell somewhat on the third day of the paralysis, but remained more elevated than natural, in the evening, for several weeks, with occasional rises. Thus, on one or two occasions it suddenly rose to 102° ; and on one occasion to in the evening, and then quickly became normal. During the child's stay in the hospital there was no sign of embolism of other organs. Her right leg rapidly improved, and she regained the power of walking ; but the arm continued powerless, and when discharged on August 14th, the patient was still unable to speak.
In this girl there was doubtless a congenital lesion of the heart, consist ing in part of narrowing of the pulmonary artery, and, as a consequence, the right side of the heart had become hypertrophied. It is probable, also, that there was insufficiency of the mitral valve, from endocarditis occurring after birth ; and that it was from this source the embolus was derived, which had become arrested in the middle cerebral artery.
In another case, a boy, aged eleven years, who was suffering from steno sis and insufficiency of the mitral orifice, was taken suddenly with paralysis of the right side, combined with difficulty of speech, while recovering from an attack of small-pox.
It is not always in the arteries of the brain that the embolus is arrested. The fragment may lodge in the kidney, producing albuminuria; in the liver, causing enlargement and slight jaundice ; and in the spleen, leading to perceptible swelling of the organ. In the latter case, according to Dr. Gee, the infarction is peculiarly liable to be associated with fever of the hectic type, without the endocarditis to which it is owing being necessarily ulcerative.
There is one other result of embolism which may be noticed, although its consequences are not so immediately obvious. Aneurismal dilatations in the child are now known, from the researches of Dr. J. W. Ogle and others, to be due to this accident. Aneurisms seated on the small arteries of the brain, leading to fatal hemorrhage, sometimes occur in young sub jects, and are doubtless to be attributed to plugging of the vessel by this means. The same condition is also occasionally seen in the larger arteries, as the external iliac.