The murmur of endocarditis soon after its appearance is only rarely so harsh in childhood that it can be mistaken for the friction murmur of pericarditis. On the contrary, however, pericardial friction murtnurs may be so soft in children that it is difficult to tell them from endo cardial murmurs. As, besides, in a considerable number of children endocarditis appears simultaneously with pericarditis, the murmurs heard in auscultation may sometimes be very difficult to explain, in the very acute cases of inflammatory cardiac atTections of children. The superficial and noncontinuous character of the pericardial friction murmurs which is not completely concealed by the phases of the heart, their slight transmissibility and their accentuation when pressure is made with the stethoscope are also observed. Sometimes the exist ence of a pericarditis in addition becomes plain from the fact that the murmur, in parts of the thorax far from the precordial region, is quite different in character from that heard at the apex and over the left ventricle. That the pericardial friction murmurs are frequently only heard in children during ventricular systole has already been mentioned in the section on pericarditis. The diagnosis of acute endopericarditis of childhood becomes more probable when, in spite of the essential symptoms of endocarditis and in spite of a strong pulse, with loudly audible murmurs. the apex-beat appears to be weakened.
Course and endocarditis of childhood may lead to complete recovery or to chronic changes in the valvular apparatus of the heart, or in rare cases may end in death from complications. Malignant or ulcerative endocarditis, which will be briefly described later, always leads to a fatal termination rapidly.
According to the observations of Steffen, Hochsinger and Weill, an acute endocarditis in children, rheumatic or scarlatina], or parietal endocarclitis also, may completely disappear within a few weeks, with the gradual disappearance of the murmurs. Affections of the aortic valves do not show this involution ability. Most inflammations of the valvular endocardium lead to permanent cardiac lesions. from contrac tion of the vegetations, in part, too, from calcification of the valvular excrescences and of the valves themselves.
Death may result in the benign form of endocarditis also, from association with pericarditis, pericardial adhesion or embolic processes in the brain. One of the important resulting conditions in childhood is cerebral embolism, producing herniplegia. In a case of Hochsinger's, affecting a child of three and a half years, right hennplegia occurred toward the end of the second week of an acute scarlatina! endocarditis, marked by a low blowing murmur.
The prognosis as to life, may in general be favorable if there are no points to support the presence of pericarditis at the same time. While most cases of endocarditis of childhood lead to permanent valvular lesions, nevertheless, death hardly ever occurs in uncomplicated cases, during childhood, but only in later life.
Malignant (Ulcerative) Endocarditis As a result of the high virulence of the causative micro-organisms severe pycemic or typhoid symptoms occur on the one hand; while, on the other, the rapid destruction of portions of the inflamed valves and endocardium brings about a violent eruption of serious symptoms of eardiac insufficiency, among which acute dilatation, with loud murmurs at all of the ostia, comes first. S. Adams was able to collect 47 cases of septic endocarditis in childhood, with recovery in three cases.
-When heart murmurs are also present, the diagnosis can sometimes be made in childhood, as was done in two cases by Hochsinger. Murmurs are absent very frequently (Jacobi) and are replaced by embryocardial or gallop-rhythm which may cause insurmountable obstacles to the diagnosis. This is the rule in early childhood especially, when the seat of the ulcerations is parietal and the endocarditis is associated with pulmonary affections.
From an often puzzling illness, resembling typhoid, irregular malaria, miliary tuberculosis or pyceinia, children with ulcerative endo carditis may suddenly develop a serious cardiac symptom-complex, with the appearance of loud cardiac murmurs. This is the case if pari etal ulcerations advance into the myocardium and produce perforation of the septum or cardiac and valvular aneurysms. Tinder these con ditions the symptoms of septic emboli appear rapidly. Capillary emboli of the skin, with purulent or hamiorrhagic efflorescences, paralyses appearing suddenly, intestinal and renal hannorrhages, widespread areas of pulmonary dulness, with high fever and loss of consciousness, mark the embolic, septic character of this morbid process which always leads to death.
According to Baumgarten, in the inajority of cases, the staphy lococcus aureus and the streptococcus pyogenes act together to produce ulcerative endocarditis, the chief part as regards the ulcerations being attributed to the latter, however. But the colon bacillus, different proteus forms and other micro-organisms have also been found.
Malignant endocarditis may attack children in perfect health or it may also develop in the course of other infectious diseases, caused by tbe microbes of the disases (typhoid fever, streptococcus pneumonia, ulcer ative colitis, erysipelas). Ulcerative endocarditis may also be joined to chronic endocarditis and pericarditis.