Even a patent foramen ovale without constriction of orifices or other abnormal condition will give rise to a murmur. In a case published by Dr. Balthazar Foster—in a little girl of two years old—a faint murmur was heard with the latter part of the first sound at the level of the lower edge of the third rib at its junction with the sternum. It did not, however, extend over a wide area, and was audible neither at the base of the heart nor the apex.
Infants who suffer from congenital malformation of the heart are usually thin. If, however, the patient survive the period of infancy, he may not be wasted and• may even have a sturdy appearance. He is usually lethargic and dull of intellect ; and is cautious in his movements, as experience has taught him that exertion is apt to be followed by palpi tation and dyspncea. In most cases where. serious malformation of the heart exists the patient is subject to attacks of syncope, and often symp toms occur referable to disorder of the nervous system. In the case re ferred to above, the patient died of cerebritis. Another cyanotic child under my care in the East London Children's Hospital—a little girl nearly two years old—suffered, while she remained under observation, from general loss of power, with ptosis of the right eyelid and contraction with rigidity of the muscles of the left forearm. The child had all the signs of carious disease of the right petrous bone. Disease of this part of the skull seems to be a not uncommon lesion in children who suffer from congenital mal formation of the heart. Dr. Lawrence Humphry has kindly communicated to me the notes of a case which occurred during his period of office as Resident Physician in the Victoria Park Hospital. The patient—a cyanotic boy between five and six years old—had suffered from long-continued otorrheea. A fortnight before his death the discharge ceased. The child then began to complain of headache, which became very severe. This symptom was soon followed by attacks of violent convulsions, without loss of consciousness in the intervals, and the boy died in a few days. After death, in addition to the ordinary form of congenital malformation (stenosis of the pulmonary artery, deficiency in the ventricular septum, and origin of the aorta from both ventricles) an abscess was found in the middle lobe of the left cerebral hemisphere, and the petrous bone on that side was dis eased.
Convulsions are very common, especially in infants ; and startings and twitchings during sleep are seldom absent whatever be the age of the pa tient. Another curious symptom is great heaviness and somnolence. In many cyanotic children attacks of uncontrollable sleepiness form a promi nent feature in the case. These attacks are apt to come on after a meal. The child shows symptoms of great drowsiness ; the face becomes purple, and the breathing slow and heavy. In extreme cases the sleep becomes so profound that it resembles coma and the child cannot be roused. After some hours, however, the patient revives, his heaviness passes off, and he is restored to his normal condition.
The duration of life is very variable. It is dependent chiefly upon the degree of obstruction to the circulation. Nearly one-half of the cases die before they have completed the first year, and two-thirds before they are two years old. Death often occurs in a convulsive fit ; and infants usually die in or directly after such a seizure. ° Moreover, attacks of syncope are common, and the failure of the heart's action is sometimes not recovered from. In some cases the patient falls a victim to pneumonia or other in tercurrent disease ; indeed, on account of the impaired state of nutrition usually prevailing, the resisting power of the child is feeble, and derange ments prove fatal which a stronger subject would have little difficulty in overcoming. Many of these children become tubercular or phthisical, and, as has been said, in not a few cases death is preceded by symptoms point ing to cerebral mischief.
Diagnosis.—A child, cyanotic from malformation of the heart, presents a very characteristic appearance. His dusky tint, his purple lips and eye lids, his livid and clubbed finger-tips—these symptoms, together with the physical signs and the history of the patient, can leave little doubt as to the existence of a congenital lesion of the heart. If, however, cyanosis is ab sent, the nature of the case is less immediately recognisable ; but by a care ful review of the physical signs we can usually arrive at a correct conclu sion. If we are able to localize the murmur at the pulmonary orifice, and can ,discover signs of hypertrophy of the right ventricle (increase of the heart's dulness to the right with pulsation in the epigastrium), these signs are almost pathognornonic of congenital disease, ror endocarditis affecting the right side of heart is rare after birth. Sometimes, on account of the small size of the chest in young subjects, it is impossible, especially in an infant, to discover the point of greatest intensity of the murmur. In such a case, signs of hypertrophy of the right heart are doubly important ; and if we notice clubbing of the finger-ends, and find that after movement the child's face becomes livid or his lips blue, the existence of congenital heart disease, in the absence of any affection of the lungs, may be safely as serted. According to some observers, attacks of dyspncea alone, occurring from trifling causes, are very suspicious of this form of lesion. Louis was of opinion that " suffocative attacks brought on by the slightest cause, often periodic, always very frequent, and accompanied or followed by syn cope, and with or without blue cliscolouration of the body, generally" formed sufficient grounds for the diagnosis of an abnormal communication between the right and left cavities of the heart. Again, the occurrence of tubercu losis in a child the subject of old-standing heart disease, although not con clusive evidence, points very decidedly to a congenital origin for the car diac mischief.