The cyanotic tint is not always an early symptom. We often find that the child at birth presented no peculiarity of colour, and that it was only after an interval of weeks or months that anything was noticed to excite suspicions of disease. In less common cases the tint of the skin is normal throughout.
In addition to the blueness of the ends of the fingers and toes, these parts are usually clubbed from systemic venous congestion, and the nails are incurvated. The shape of the chest is often peculiar. It is sometimes called "pigeon-breasted," but the prominence of the sternum is only no ticeable at the lower part from flattening in each infra-mammary region. Al the upper part the chest is abnormally prominent and rounded. The coldness of the hands and feet is another striking peculiarity in a cyanotic child. Indeed, the external temperature of the body may be several de grees below the normal level ; but if the thermometer be placed in the rec tum the internal temperature will be found little lower than natural. It is, however, subject to variations, being sometimes for several days below the normal level ; at other times more nearly natural. In these patients, as in healthy children, the ordinary heat of the body is liable to be disturbed by teething and other sources of irritation ; and is sometimes found to run up to 102° or even higher from this cause.
Dyspncea and palpitation of the heart are common symptoms. In the case of an infant the mother often remarks upon the beating of her child's heart when the patient is or otherwise disturbed ; and older chil dren may complain spontaneously of the throbbing when they attempt to run. At these times there is usually shortness of breath, and cough may be present. In some cases when the cyanosis is extreme, the cough may be accompanied by the expectoration of blood. The pulse is often irreg ular and intermittent, but its strength is fair.
Sometimes dropsical symptoms come on. There may be cedema of the legs, or ascites ; but serous effusions are less common than might be supposed, for, as Dr. Chevers has pointed out, the venous system seems to adapt itself to the overloading. The right auricle, cava, and systemic veins are often of unusual capacity from the first ; and the veins of the liver are capable of containing a vast quantity of delayed blood. The superficial veins of the chest or limbs are rarely more visible than natural, but the skin is habitually dry and may be harsh. The liver and spleen can often
be felt to be enlarged ; and on account of the congestion of the kidneys the urine is habitually scanty and high coloured. On account, too, of the congestion of the alimentary canal, the tongue is generally foul, the breath offensive, and the digestion feeble. The appetite is poor or capricious ; and the bowels costive or irregular, with clay-coloured pasty stools. The gums are often dark-coloured and spongy-looking, and may be ulcerated at their edges. Sometimes they bleed.
Cyanotic children are generally irritable and easily disturbed. Conse quently at a first examination it is often impossible to come to a satisfac tory conclusion even as to the physical signs present in the case. These are liable to vary according to the character of the congenital lesion, and may possibly be absent altogether ; for if the malformation consist in a mere transposition of the aorta and pulmonary artery, without narrowing of the channels or persistence of the foetal openings, no murmur will be heard, and careful examination will detect no sign of cardiac enlargement. The most common malformation, as has been said, is that in which the pulmonary artery is greatly constricted, and the septum between the ven tricles is deficient, so that the aorta appears to arise in part from the right ventricle. In such a case there is great hypertrophy of the right ventricle ; we find a very strong pulsation all over the prmcordial region, and a forcible impulse between the left nipple and the ensiform cartilage. The impact may be accompanied by a systolic thrill. On listening to the chest we hear a loud systolic murmur in the course of the pulmonary artery. In the case of a boy who died at the age of nearly six years in the East London Children's Hospital with this condition, the apex beat of the heart was in the fifth interspace in the nipple line. The impulse was felt very strongly over the whole prdecordial region, in the epigastrium, and even to the right of the lower part of the sternum. The arteries in the neck also pulsated strongly. A loud systolic murmur was heard all over the front and back of the thorax. It was rather louder at the base of the heart than at the apex., and became much fainter towards the armpits. The point of greatest intensity was over the site of the pulmonary valves. In this child there was no discolouration of the skin.