Prognosis.—As long as the cardiac lesion gives rise to no symptoms, the prognosis is very favourable. If a mitral murmur, although harsh in qual ity and high in pitch, be accompanied by no signs Of hypertrophy of the left ventricle, there is reason to hope that it may ultimately disappear. If signs of enlargement of the heart are noticed, we cannot expect that the valvular lesion be recovered from ; for a temporary dilatation of the left ventricle, such as is apt to occur in chlorotic girls, I do not think is common in the child ; but as long as the health of the patient seems to suffer in no way from the disease, little apprehension of immediate danger need be entertained. Directly, however, any symptoms are noted indi cating impairment of nutrition or obstruction to the circulation, there is cause for anxiety. Serious breathlessness, lividity on slight exertion, marked ansemia and perceptible loss of flesh, are all unpromising symptoms.
The prognosis is more favourable in cases of mitral insufficiency than of mitral stenosis. If the mitral disease has led to tricuspid insufficiency, speedy dilatation of the cavities of the heart may be anticipated. When signs of dropsy begin to be perceived, the danger is really imminent. By judicious treatment and careful nursing the end may be postponed, but cannot in any case be far distant.
Attacks of rheumatism and chorea, being apt to aggravate the valvular lesion, are greatly to be dreaded ; and all forms of inflammatory chest affection, as they increase the work of the heart, are likely to have injurious consequences. Embolism is a very serious accident. If the embolus lodge in the middle cerebral artery and produce hemiplegia, the complica tion, although it may not destroy life, may lead to permanent impairment of movement of the limbs. In the second of my cases of cerebral embolism referred to above—a boy eleven years old—the patient, two years after the attack of paralysis, had very little use of the right arm. He could walk, however, and had recovered the power of speech. If the brain be un affected, and the embolism occur in other organs, the resulting irritation and disturbance may prove fatal, even although the fragment detached from the valve be destitute of any infective property.
Treatment.—In cases where a valvular lesion exists producing any sign of inconvenience, there is no reason for special medication. The parents should, however, be cautioned to spare the child all unnecessary fatigue, and to prevent him as much as possible from taking part in violent exercises. Excitement of the heart should be prevented. In the case of a schoolboy this is, of course, a matter of great difficulty ; for, as long as the child is untroubled by uneasy sensations, he cannot be convinced of the necessity for quiet. Little girls are fortunately less addicted to boisterous games. Measures should be taken to prevent fresh attacks of rheu matism, and the child should wear woollen underclothing all the year round.
Directly palpitations, breathlessness after exertion, or anaemia, begin to be noticed, more active measures must be taken. Too energetic action of the heart must be quieted by digitalis. This valuable drug has always seemed to me to be well borne by young patients. The best form in which it can be given is the infusion, of which a child of ten years old will take, without any inconvenience, two drachms three times in the day. On ac count of the importance in these cases of keeping up a gentle action of the bowels, I usually combine the remedy with a mild aperient and a vegetable bitter. One drachm each of the infusions of digitalis, senna, and calumba,
given three times a day before meals, is often followed by great benefit ; or, if desired, the proportion of diaitalis may be doubled. If the diges tion is weak, a few drops of dilute nitric acid may be added to the draught. When any signs of anaemia are present, iron should be given in addition. This medicine is best administered separately, and I pre fer the exsiccated sulphate in these cases to all other forms of iron. Four or five grains of the salt may be given in glycerine directly after each meal. .
Great care is necessary in the matter of diet. The child is not to be overloaded with food because he is weakly and seems to be losing flesh. His meals should be small, that his stomach may not be oppressed • and the quantity allowed should be such as his digestion can bear and his tissues readily assimilate. If the blood be overcharged with superabundant material which is useless for purposes of nutrition, extra work is thrown upon the excretory organs, whose duty it is to eliminate it from the system. It is well to order four small meals in the day, of which one may consist of meat with vegetables, a second of a piece of fish or an egg, and the two others of milk and bread and butter. The quality of the food should be also attended to. All rheumatic subjects have a special tendency to flatu lence and acidity ; and this tendency is favoured by excess of starchy mat ters and sweets. It is often remarkable to note the immediate improve ment which takes place in the condition of a child who has been pampered and overfed " because he is delicate," when these simple rules are at, tended to.
When dilatation of the heart occurs, and leads to stasis of blood in the systemic veins and general cedema, diuretics are indicated. This condi tion must be treated in the child upon the same principles as are followed in the case of the adult. The kidneys must be stimulated to act by the acetates of potash and ammonia, spirits of nitrous ,ether, juniper, fresh broom tops, squill and digitalis. One especially valuable diuretic in these cases is the tincture of cantharicles. I have seen a formidable amount of dropsy clear away completely in a child of nine years old under the influ ence of ten drops of this remedy given three times a day, after other means had been used without making any impression upon the effusion. I have tried the resin of copaiba, but the drug has proved of little service in my hands. Drs. Leech and Brackenridge speak highly of the value of caffein. The action of diuretics is greatly aided by dry-cupping the region of the kidneys, and afterwards applying a succession of hot linseed-meal poultices to the loins. For aperients, I prefer the compound jalap powder to elaterium, which has a very uncertain action on the child. Stimulants are of service, and unsweetened gin may be given in suitable doses as re quired. If it be necessary to puncture the legs, Dr. Southey's cannulEe should be employed ; and Dr. Goodhart's suggestion that these instru ments should be steeped in some boiling germicide before being used, is one of distinct practical value.
When embolism occurs in a cerebral artery, producing hemiplegia, the bisulphite of soda may be given in doses of ten or fifteen grains three times a day. This drug has a marked action in rapidly relieving the phlebitis which is so common in women lately delivered ; but my experi ence is too small to enable me to speak confidently of its value in the cases above referred to.