Six leeches were applied to the region of the heart. They bled freely, but the symptoms continued, the lividity deepened, and the boy died in a few hours. No examination of the body was allowed ; but there can be little doubt that death was occasioned by ante-mortem clotting in the heart or large vessels near their origin.
Diagnosis.—The existence of a valvular lesion of the heart is ascertained almost as readily in the young subject as it is in the adult. Even if a child cry during the examination of his chest, the heart sounds can usually be perceived during the short interval of inspiration. In most cases, how ever, if the patient be not frightened by abruptness of movement, and if he be allowed to play with the stethoscope before the instrument is applied to his chest, a young child will submit to the process of auscultation with out any complaint.
When a murmur is detected, we have to decide if it be of recent origin. A recent murmur is soft and of low pitch ; but as time goes on it becomes harsher and its pitch rises. If the lesion affect the calibre of the orifice at which it is generated, or interfere with the closure of the valves, it soon leads to some enlargement of the heart and alteration in the position of the apex-beat. If, in a child who is suffering from acute or sub-acute rheumatism, we detect a harsh, high-pitched, systolic murmur at the apex, we may conclude that the cardiac lesion dates from a period considerably anterior to the existing illness. In noting the position of the apex-beat, and its relation to the nipple, it is important to remember that in many children the nipple lies at a lower level in the chest than is the case in the adult. Instead of the fourth rib, it is often placed on the upper border of the fifth. In such a subject the normal position of the apex-beat would be in the fifth interspace just below the nipple and slightly to its inner side.
In every case of indisposition in the child, however apparently trifling it may seem, the heart should be carefully examined, for, as has been said, a valvular lesion may be present without giving rise to symptoms of dis comfort, and evidence of disease is sometimes found very unexpectedly. There are, however, certain combinations of symptoms which should at least excite suspicion. Attacks of palpitation in the child are less com monly than in the adult the consequence of functional derangement or dyspeptic disorder, and, if present in a marked degree, should suggest cardiac mischief. Frequent epistaxis in an anemic child is not uncom monly the result of mitral disease ; and if a child who is not anemic becomes breathless after exertion, especially if the shortness of breath is accompanied by lividity of the lips, the symptom should excite the strongest suspicions.
The presence of a murmur at the apex is not in itself sufficient evidence of a serious lesion. Heart murmurs in children not uncommonly disappear. This statement is true not only of recent soft murmurs, such as are heard in cases of chorea or acute rheumatism, but also of louder and harsher murmurs which are known to be of longer duration. In all cases where a harsh murmur is detected, signs of hypertrophy of the left ventricle should be searched for. If no enlargement be discovered, and the apex-beat re main in its normal position, it is highly improbable that any serious val vular defect is present (see page 163). The apex-beat of the heart may, however, be in an abnormal position without the alteration in site being the result of endocardial disease. The causes which lead to displacement of the organ are referred to elsewhere (see page 402).
Again, a basic heart murmur may be produced by causes acting from without. Pressure upon the large vessels by caseous bronchial glands may so narrow the channel as to give rise to a systolic murmur. In these cases, however, other signs will be found, explanatory of the abnormal phenomenon (see page 181).
The detection of a cardiac murmur will sometimes furnish an explana tion of symptoms which would be otherwise obscure. In all cases where hemiplegia occurs suddenly in a child, attention should be at once directed to the heart. But mere pyrexia is sometimes caused by embolism in other organs, where irritation and disturbance give rise to less characteristic symptoms than are found when a portion of brain is suddenly rendered useless. In cases of ulcerative endocarditis, continued high temperature, and a condition bearing a close resemblance to enteric fever, may be in duced, by the accident; but even when the fragments of organic matter thrown off from the valves have not this infective character, an irregular pyrexia may be set up. Careful search in these cases will often discover some local symptoms suggestive of the presence of an infarct. The spleen may be found to be swollen ; the liver may be enlarged, with slight jaun dice ; albuminuria may occur from embolism of a kidney ; or petechice may be noticed in the skin from obstruction to the circulation through the cutaneous capillaries. In all these cases the source of the mischief will be discovered on examination of the heart.