Affections closely related to rheumatism, purpura and erythema multifornie, also bear an etiolog,ic relation to the endocarditis of chil dren. Rheumatic iritis has been .seen combined with endocarditis, as with chorea also (Hohlfeld, Forster).
Of the other fundamental diseases to which endocarditis in child hood may be due, chorea come.s first, causing 15 per cent. according to Weill, 13 per cent. according to Bonnaucl, and 15 per cent. according to Hoehsinger, of the cases of endocarclitis in children. From Ilochsinger's experience, about one half of all children with chorea develop endo carditis, some with, others without symptoms of rheumatism, a condi tion which supports the opinion, advanced at present by Cheadle and Heubner, that chorea is a rheumatic equivalent. Cassel who does not consider this relation between rheumatism and chorea established, found rheumatism fifteen times among 38 children with chorea; and rheumatism, chorea and endocarditis together nine times. In no other disease, besides, is the differential diagnosis between organic and acci dental heart murmurs so difticult as in chorea minor.
According to Weill a frequent anatoinic finding with general tuber culosis of childhood, especially with tuberculous nieni4tis, is tubercu lous endocarditis of the valves of the heart, which, however, does not lead to functional disturbances.
Among the exanthematous infectious diseases, scarlet fever stands first in causing endoearditis, yet the figures vary with the nature of the epidemic. Complete recovery occurs from the endoearditis of scarlet fever especially frequently. Pnemnonia, epidemic influenza and en demic "grippe" should also be mentioned as more frequent causes of endocarditis. Endoearditis following measles and gonorrhcra is a great rarity in childhood.
Idiopathic endocarditis is not acknowledged by many writers (Cheadle, von Dusch) who believe these cases to be dependent upon rheumatism which has been overlooked, or to be primary rheumatism of the endocardium. But tlie exclusive appearance of cases of idio pathic endocarditis in children during the first four years of life, when rheumatism occurs uncommonly rarely, is hardly in favor of the above mentioned view. From flochsiuger's observations, he considers the
occurrence of an idiopathic endocarditis, comparable to fcetal endocar ditis, as absolutely established in early childhood.
So, too, the occurrence of a purely traumatic endocarditis in chil dren cannot be denied (cases of Prandi in a boy of 8, and of kantorow itz, in a boy of years).
According to Vianello and Cacchiole, ordinary infections of the nasal, pharyngeal and laryngeal mucous membrane play a part which should not be undervalued in the genesis of endocarditis.
Pathologic verrucose, sclerotic and ulcerative endoearditis are to be differentiated. The first two forms of cndocarditin run a benign course in childhood as a rule, though they only rarely lead to complete recovery, while the last form almost always leads to a fatal termination.
The anatomical picture of endocarditis in childhood hardly differs from that of adults. In the verrucose form rose-red outgrowths, not unlike verruca acurninata, arise fIS result of vegetation of the fibrous layer of the endocardium, on the side of the valves facing the ostium, with destruction of the covering epithelium. These may be totally reabsorbed or undergo a fibrous change, with contraction of the valvular al,Paratus, front which stenoses of the ostia and inability of the valves to close may result (chronic endocarditis: valvular heart lesion) The ulcerative form is different, in that the granulation tissue, rapidly forming upon the valves, is broken up by ulceration, which may lead to destruction of the valves, erosion of the chordce tendinew and papillary muscles, and finally to purulent myocarcLitis. If infectious matter from the endocardium is carried off by the blood, abscesses may be caused by emboli in the most remote organs, the kidneys, spleen, liver, lungs or central nervous system.
Embolic processes may also occur in verrucose endocarditis, from separation of particles of the valvular excrescences, which produce hamorrhagic infarcts. Finally, that papillary vegetation and ulcera tive processes may also occur on the parts of the endocardium apart front the valves (parietal endoearditis) should be noted.