Acute endoearditis of the aortic valves in children also gives rise to a systolic murmur, with its point of maximum intensity; at the second intercostal space to the right of the sternum, and is the result of un evenness of the valvular ring and the edges of the valves, due to ver rueose efflorescences upon the valves. Only when true insufficiency of the valvular apparatus occurs, i.e., after the process has lasted some time, are diastolic murmurs heard at the aortic ostium. On the whole, diastolic aortic. murmurs are very rarely found during the first years of life, with acquired heart affections.
Percussion of the heart gives fewer positive signs than auscultation in acute endocarditis in children, because an increase in the heart dul ness may not be certainly shown clinically for a long time, or may even be absent during the entire course of The disease, in cases which end in recovery. This is in part clue to the extraordinary resistance of the cardiac. muscle in children, which prevents dilatation of the heart cavities; in part it depends upon the difficulty of estimating, by per cussion, slight grades of dilatation of the left auricle which next conies into question in acute mitral endocarditis of childhood. An increase in the size of the right side of the heart which appears rapidly in endo carditis of adults is absent for a long time in the endocarditis of children, because the compensatory overwork of the left ventricle causes it to empty itself so thoroughly into the aorta that congestion in the pul monary cireulation is prevented for a long time. The first and only sign of a backward action upon the right side of the heart in the acute rnitral endocarditis of children is as a rule accentuation of the second sound at the pulmonary area only, and this symptom may be lacking for a long time. Thus, in children, there may be a stage lasting weeks in which a systolic heart murmur is the only physical sign of acute enclocarditis.
The functional symptoms of the acute endocarditis of childhood are very varied. Subjective symptoms are absolutely absent in some children. Sometimes older children complain of pain in the precordial region or pain piercing the left side of the chest suggesting pleurisy, or the pains blend with rheumatic pains which often exist at the same time. Oppression in the chest, anxiety and restlessness are usually present. only when pericarditis accompanies the endocarditis. One symptom frequently present is a sort of nervous shortness of breath, which appears with bodily exertion, talking, crying or the slightest psychical excitement, and cannot be explained by the other objective findings.
Acute endocarditis in children always begins with a rise of body temperature. If it complicates another febrile disease, it produces an exacerbation of the fever, or if the temperature of the fundamental disease has already reached normal, it rises again with the endocar clitis. No certain type of fever prevails. The temperature may return to normal rapidly and shoot up again with new attacks, frequently marked by the recurrence of rheumatic pains. Then there arc cases of idiopathic endocarditis in early childhood in which Hat' rise of tem perature is slight, sometimes only ephemeral, and a cardiac murmur, only appearing later, shows that the fever observed previously was the initial fever of endocarditis.
The pulse-rate is always accelerated but its rhythm usually remains unchanged.
ft cardiac murmur appears in the course of or as a result of polyarthritis or the infectious diseases, with It rise in body temperature, remains permanently and is not modified by pressure with the stethoscope and by respiratory pauses, it always points to acute endocarditis. Difficulties may arise in the interpretation of the mur murs, as it may sometimes lie necessary to distinguish the murmur of simple fever from organic cardiac murmurs (see p. 456). Sometimes the differentiation between acute endocarditis and acute dilatation of the heart, with relative insufficiency' of the mi-tral valve, may be difficult in childhood. With regard for the high compensatory tendency of the cardiac muscle in children, mentioned in the symptornatology of endo carditis in childhood, as opposed to the acute changes of endocarditis, when cardiac dilatation, together with a systolic murmur, appears rapidly, the decision will always result in favor of a dilatation insuffi ciency of the tiara] valve. The same thing will also come into question in nephritis, chronic pneumonia, cardiac insufficiency as the result of septic diseases, and chronic myocarditis with acute cardiac insuffi ciency, in children. Several cases of heart murmurs, reported in lit erature in little children without anatomic changes of the valves, which on that account were considered accidental, depended upon relative insufficiency of the mitral valve.