Besides embolism, other occasional complications may be observed in cases of heart disease. On account of the rheumatic disposition of the majority of such patients, evidences of that constitutional state are often observable. Skin eruptions, especially eczema, erythema, and urticaria, are common ; pleurisy and pericarditis are not unfrequent lesions ; and joint pains are often complained of. Another common complication is some form of nervous derangement. Chorea is liable to occur in the subjects of heart disease ; and Dr. Sansom has remarked the occasional association of epilepsy with cardiac inischie£ In some cases, impairment of nutrition is the only evidence of ill health. A little boy, aged seven years, was brought to the hospital with signs of mitral stenosis and insufficiency. Still, the boy had no cough, and did not appear to be breathless on exertion. For six months, however, he had been persistently wasting, although, with the exception of occasional abdominal pains, there was no evidence of digestive derangement, or other sufficient cause for the impaired state of his nutri tion. In some cases the wasting is combined with anaemia, which may even reach an extreme degree.
The most common form of heart lesion met with in childhood is regur gitation through the mitral orifice. Next in order of frequency is regur gitant combined with constrictive disease. Then follow a combination of constrictive and regurgitant disease of the aortic orifice, and constrictive disease alone. Stenosis of the mitral orifice, unaccompanied by insuffi ciency of the valve, is not common in the child ; and regurgitation through the aortic orifice is far rarer than it becomes in after-life years. It will be unnecessary to describe the physical signs and special symptoms connected with these various lesions, since they do not, as a rule, present any peculi arities dependent upon the early age of the patient. With regard, how ever, to aortic regurgitant disease, it may be remarked that this form of heart lesion, as has been preViously stated, is not always accompanied in the child by any striking pallor of the complexion ; nor is it often cated by any marked alteration of the pulse. The pulse is regular, and is weakened by raising the hand above the head ; but the characteristic hammer-like beat of the artery is usually absent. Moreover, the pulsation of the more superficial vessels, although visible if narrowly looked for, is seldom sufficiently marked to catch the eye unsought.
Terminations.—When death occurs in cases of heart disease, during childhood, the fatal event is often brought about by some inflammatory complication. Children so afflicted are more weakened than is the case with a healthy subject, by casual derangements, and have less vigour with which to bear up against a serious disease. When death is due directly to
the heart lesion, it generally occurs in cases where the pericardium has become firmly adherent to the substance of the heart, and has led to serious interference with the nutrition of the organ. The cavities become greatly dilated, and the feeble walls are no longer equal to the discharge of their functions. Great congestion of the lungs follows, and there is general stasis of blood in the systemic venous system, with its inevitable conse quences. In most cases of death from cardiac dropsy, the pericardium is found firmly adherent to the heart.
Sudden death is not very common from cardiac lesion in the child. When it takes place it is probably the result of clotting of blood in the large ves sels of the heart. A little girl was under my care in the East London Children's Hospital for chorea, which had followed closely upon an attack of sub-acute rheumatism. The child was low and depressed, and her com plexion was markedly anmmic. The choreic movements were bilateral, affecting the face, tongue, and eyes, but were only moderate in degree. When she took food into her mouth, the muscles of deglutition acted con vulsively. On examination of the heart there was a loud bellows murmur at the apex, conducted well into the axilla. This evidently dated from some previous attack of rheumatism. During the girl's stay in the hos pital, fibrous nodules were developed on the tip of each spinous process of the vertebr. The child was treated at first with chloral ; afterwards, with quinine and iron. She took three ounces of port wine daily. In spite of the treatment, she wasted, and seemed to grow weaker. After a time, as no improvement occurred, the patient was removed by her friends ; and we afterwards heard that she died quite suddenly on the following day. No post-mortem examination was obtained.
Sometimes the clotting takes place more slowly. A little boy, suffering from mitral regurgitant disease, with much dilated hypertrophy of the left ventricle, was noticed for two days to be uneasy and restless, with some dulness of manner. On the third day he was seized with dyspncea, which became gradually more severe. The child grew excessively restless, and threw himself about in his bed. When I saw him (at 3 P.M.) he was sitting up in bed, supported by the nurse. His eyes were staring and wild-look ing, his face much congested, his lips and cheeks purple, his finger-nails blue. The breathing was laborious, and the flares acted. The heart's ac tion was excited and forcible, but the pulse at the wrist was excessively weak. The boy was very restless, constantly changing his position and throwing his arms about. He was quite sensible, and made no complaint.