Even in cases where all necessary symptoms are present, and the con genital origin of the heart-lesion is unmistakable, the exact variety of mal formation must often remain a mystery. The difficulties in ascertaining the form in which the arrest of development has occurred are very great. In the case of a fully developed heart we are dealing with an organ the structure of which is known. We are acquainted with the number and situation of its openings, the number and mechanism of the valves which close them, and the direction normally taken by the current of blood. In such a heart any morbid alteration of the physical signs has a definite meaning ; and in ordinary cases there is little uncertainty as to the cause which has given rise to it. In the case of a heart the seat of a congenital malformation, the conditions are very different. The number of openings is undetermined ; their position is doubtful, and even the direction in which the blood is flowing can only be conjectured. In such cases, there fore, an exact diagnosis is often impossible. Still, there are certain general rules which should not be forgotten. Thus, some forms of malformation prove very quickly fatal. An infant whose heart remains in a primitive state, consisting merely of two cavities, will probably be dead within a month. Therefore at a more advanced age this variety may be excluded. Another form of congenital disease which usually has an early termination is transposition of the aorta and pulmonary artery. Children in whom this form of malformation occurs rarely live longer than two or at the most three years. One little boy under my care with this form of lesion sur vived to the age of eighteen months ; but the majority of the recorded examples have died within the twelve months. So, also, the variety which consists in the origin of the aorta from the pulmonary artery is not likely to be present in a child who has survived the first year.
In children who have reached the age of three years the above condi tions may be excluded with a high degree of probability. At this age we should search for signs indicative of atresia of the pulmonary artery. If we can localize the murmur over the pulmonary valves, and can ascertain the existence of hypertrophy of the right side of the heart, we may safely infer the presence of contraction of the orifice of the pulmonary artery. In such a case there is probably also deficiency of the ventricular septum, with a communication between the aorta and the right ventricle, and per haps patency of the arterial duct. This, it may be repeated, is the commonest form of congenital malformation. Still, other morbid condi tions of which we know nothing may also be present. Patency of the foramen ovale is seldom the only abnormality, but, if in a child of three years old or we find the symptoms of congenital heart disease without cardiac murmur, or with a very faint bruit limited strictly to the level of the third interspace towards the middle line, and without signs of hypertrophy of the right ventricle, this condition may be suspected. In no case, probably, can a positive diagnosis be arrived at ; at least, we can never say that the condition diagnosticated is the only cardiac lesion present.
Prognosis.—The prospects of a child, the subject of congenital mal formation of the heart, are necessarily very mifavourable. On account of the difficulties under which his circulation is carried on, and the persistent congestion of his whole venous system, the child's nutrition is faulty and his vitality low. He has therefore little power to throw off even trifling derangements, and is peculiarly sensitive to disturbing influences. In ad
dition, then, to the dangers directly attendant upon his congenital defect, he is exposed to constant risk from the serious consequences, in his en feebled state, of the ordinary ailments of childhood. Every change in the growth and development of the infant is a new period of trial. The first establishment of the respiratory function at birth, the occurrence of denti tion, the time of weaning, and all the innumerable causes of disturbance to which infant life is liable, are distinct sources of peril. To one or another of such dangers a large proportion of these patients succumb ; and, as has already been stated, hardly one-third of the whole number of cases survives to the age of two years.
On account of the difficulty of ascertaining the exact variety and extent of the cardiac defect, the prognosis during the first few months of life is especially serious. Later, as the child grows and arrives at a period when the more fatal forms of malformation may be excluded, his prospects im prove ; but they can rarely be said to be otherwise than unfavourable, for a comparatively small proportion of these patients live to attain adult years.
Of special symptoms, some should be regarded with anxiety. Frequent attacks of syncope are dangerous ; great drowsiness is of unfavourable omen ; and convulsions or other sign of cerebral irritation have a very sin ister meaning. According to Dr. Chevers, failure of the renal secretion, or the occurrence of albuminuria, as indicating the probable beginning of structural changes in organs which have always been hampered in the dis charge of their functions, is to be viewed with much apprehension.
Treatment.—The treatment of these cases consists in the adoption of wise rules for the diet and general management of the patient, and in early atten tion to any intermu•ent disorder by which he may be attacked. On account of the general sensitiveness to chills, and the tendency to lowering of the temperature, the child must be warmly dressed with a flannel band to his belly, and should be clothed in some woollen material from head to foot. His diet should be carefully arranged so as to avoid excess of fermentable matters, such as starches and sweets ; and he should be taken out of doors, whenever the weather is not too unfavourable, in his nurse's arms or a suitable carriage. If a perambulator be used, a hot bottle to the child's feet is a necessity unless the weather be warm. The patient's bowels should be kept regular, and an occasional mercurial purge is useful to afford some relief to his congested liver. If palpitations are violent, small doses of the infusion of digitalis may be given ; and Dr. Peacock speaks highly of the beneficial effects of Dover's powder. It is important to excite the regular action of the skin, which in these patients is habitually dry. Tepid baths should be given twice a day, and should be always followed by careful frictions over the whole body with the hand. Small quantities of alcohol are also of .service, ancJcmay be given in the form of brandy or the St. Raphael tannin wine. The attacks of dyspnoea are best treated by stimu lants and small doses of digitalis and ammonia.
Any catarrh, whether of the lungs or bowels, must be attended to with out delay ; and if albaminuria be detected in the urine, or the renal secre tion become scanty, gentle aperients and diuretics should be at once re sorted to. In cases of extreme discolouration, the peroxide of hydrogen has been recommended ; and Dr. Balthazar Foster states that given three times a day in eight-minim doses the beneficial effects of the remedy are very decided.