Where it is known that a child has a phthisical tendency, great care should be taken to prevent, so far as may be, its development. For this purpose the child should avoid a cold and damp atmosphere, and equally a close and impure one. If the chest be long and narrow, exercises should be practiced, with the view to its expansion, but the child's strength must not be taxed. Tepid baths and friction of the skin will do good. The clothing should be warm and free from restraint, especially as regards the respiratory movements. The diet should be most nutritious, and with a good allowance of the fatty compounds.

CHAPTER III.

DISEASES OF THE CIRCULATORY SYSTEM.

I. INTRODUCTORY REMARKS.

DISEASES of the heart and its serous covering, the pericardium, are very much more rare in the early years of life than they are after puberty; the explanation of this is due no doubt partly to the fact that rheumatism is not frequent in childhood, partly also because renal diseases are uncommon in early life, and partly because fatty degeneration of blood vessels belongs especially to the latter periods of life. On the other hand, we have sometimes to combat the distressing results produced by congenital malformations, which give rise to a large number of cardiac affections. These malformations not only produce very great suffering in themselves, but they seem to predispose to various inflammatory and other affections of the heart.

To show how rarely diseases of the heart occur in childhood, we may state that from the Report of the Registrar General for 1866, it appears that of 22,190 deaths of all ages in England from diseases of the organs of circulation, only 266 occurred under five years of age; of these latter, 35 only were from pericarditis, and 231 are set down as "Heart Disease,' &c. From five to ten years of age there were 850 deaths from this cause, and of these 107 were attributed to pericarditis.

It must not, however, be supposed that these figures represent at all fairly the frequency of cardiac disease in early life; on the contrary we know that pericarditis and endocarditis, to say nothing of the various congenital malformations of the heart, occur sufficiently often in childhood to make their study a matter of great interest and importance. In considering the pathology of chorea we pointed out the relation which it bears to rheumatism as a cause, and we may also here allude to the fact that a very close relationship exists between chorea and cardiac disease.

From a large number of cases cited by different authorities, we find that some affection of the heart exists in at least twothirds of choreic cases; but here a caution is necessary in reference to this matter, for the mere existence of a cardiac

murmur is by no means sufficient to establish the diagnosis of heart disease. There are, as is well known, many cardiac murmurs which are entirely independent of any organic disease, and these are perhaps more frequently met with in chorea than in any other affection, though still in them they are not common. In such cases of course the cure of the chorea is followed by a cessation of the murmur, and sometimes the latter will cease even though the former remains, if the general condition of the patient be greatly improved; it almost always happens that these inorganic murmurs are due simply to a vitiated or impoverished state of the circulating fluid, and that is just the condition most favourable to chorea. Where, however, the murmur persists despite the improvement in the patient's health, the suspicion of its organic character would of course be strengthened.

Dr. Andrew, in the first volume of the St. Bartholomew's Hospital Reports, has suggested another cause of these inorganic murmurs. He says that it may result from an irregular contraction of the heart, by which the natural orifice is changed from oval to round, and through which therefore regurgitation would be possible. It is well to bear this in mind, especially in choreic cases, since in them, if at all, we might look for such irregular contractions.

But after eliminating all these cases of non-organic cardiac murmur in chorea, there yet remain many cases in which organic heart disease complicates chorea, though which is to be regarded as antecedent, and whether they are in any way related, or are merely coincident, it is perhaps at present impossible to say. It may further be stated that, admitting the comparative rarity of heart disease in childhood, we must nevertheless allow that it is far more common than was formerly supposed, and may perhaps be still more so, if carefully sought after. The disease most frequently met with is no doubt endocarditis; next to that comes pericarditis, and lastly carditis. This latter is, however, so extremely rare, as scarcely to need any consideration in a treatise of this kind. Indeed it very rarely occurs as a distinct affection, but is generally combined either with pericarditis or with endocarditis, or both. We will take the other two in the order of their relative frequency.

II. ENDOCARDITIS.

Endocarditis, or inflammation of the interior lining membrane of the heart, occurs more frequently in children than is commonly supposed. It is by no means necessarily connected

with rheumatism, although that is by far the most frequent complication; but it may arise in the course of scarlatina, of measles, and also of continued fever. It sometimes occurs idiopathically.

In regard to the Symptoms of endocarditis, it is important to bear in mind that this disease may come on so insidiously and be accompanied, at first at all events, by such slight disturbance, that it is very apt to be overlooked. Hence the necessity in all cases of febrile disturbance, however slight, of a careful examination of the chest with the stethoscope. It is the one thing which alone can determine the diagnosis, and without it no really trustworthy opinion can be formed.

The early symptoms of endocarditis, whether it occurs in the course of any other disease or not, are, in addition to the ordinary phenomena of inflammation, which may in this disease be either exceedingly mild or very severe, increased frequency of pulse with occasional palpitation, irregularity of the heart's action, increased impulse with throbbing along the carotids, and more or less dyspnoea. In some cases the general distress is very great, in others it is so slight that the nature and gravity of the case may be entirely overlooked, and will probably not be recognized till some time after, when a loud cardiac murmur reveals what has taken place.

If we apply the hand to the chest in simple endocarditis, or in carditis, the action of the heart will appear to be very violent; sometimes a vibratory thrill will be felt. Percussion often discovers an augmented extent of dullness in the præcordial region; this dullness may be distinguished from that caused by pericardial effusion, by the beat of the heart appearing superficial instead of remote and distinct. If we listen to the heart's action we shall detect a bellows-murmur, the most constant and characteristic of the phenomena of endocarditis. If the murmur be systolic, most distinct at the base and along the course of the aorta, and accompanied by a small pulse, it is significant of aortic obstruction; if systolic, most distinct at the apex, and with an irregular pulse, it is due to mitral regurgitant disease. A diastolic murmur, most distinct from the centre of the sternum (on a level with the third intercostal space) upwards towards the base, with a jerking pulse, is indicative of aortic regurgitation; while a diastolic murmur, most distinct from the fourth left intercostal space downwards towards the apex, with an irregular small pulse, is the result of mitral obstruction.

The Terminations of acute inflammation of the lining membrane of the heart, or of the heart's substance, are permanent

valvular disease, followed by implication of the heart's substance with dilatation of the cavities, and all their combined consequences as general anasarca, &c. Death rarely occurs from the acute disease; and the prognosis in valvular disease is less unfavourable in children than in adults.

When, as the result of the inflammation, fibrinous concretions take place upon the valves, portions of these sometimes get detached and for a while float in the circulating fluid, until perchance they are arrested in some arterial branch, which is immediately plugged up. The consequences of this will vary according to the part supplied by the occluded vessel.

The Treatment of endocarditis resolves itself for the most part into the treatment of the affection of which it forms one of the complications-rheumatism, scarlatina, measles, continued fever. The reader is therefore referred to the chapters in which those diseases are considered. There are, however, some remedies of special value in the cardiac complications; and foremost amongst them are the so-called counter-irritants, from which we have certainly derived benefit. A blister is in our opinion of most value, if the child be not too young, he certainly ought not to be less than five years old, and even then it requires watching to prevent the formation of a slough. There is this further drawback to the use of blisters-viz., that the part is thereby made so sore that we cannot use the stethoscope till it has healed.

Warm, soothing fomentations of poppy, or laudanum and linseed poultices, are of great service, and afford much relief. Opiates internally are also useful, and aconite possesses an undoubted power of lowering the pulse and regulating the heart's action. It is therefore of great value in these cases. The dose is half a drop to a child three years of age; the same, though in a less degree, may be said of hydrocyanic acid, which is taken in rather smaller doses. Rest, and light but really nutritious diet, will aid us much in these cases; stimulants are occasionally required in rather liberal allowance.

III. PERICARDITIS.

Pericarditis, or inflammation of the external serous membrane covering the heart, may arise from cold, from mechanical injury, from a contaminated state of the blood produced either by renal disease, by the poison of scarlatina or measles, but more particularly by that of rheumatic fever. With regard to the latter it must not be forgotten, that in children the heart is liable to be affected even when the rheumatic symptoms are very mild consequently every case in which we have reason