The duration of malignant endocarditis varies. There are forms in childhood, violent at the beginning, with high fever, leading to death within a few days with septic symptoms. Other cases drag along for weeks with constantly repeated attacks of embolism and fever, until death occurs with symptoms of exhaustion. Remarkable and charac teristic of the great tenacity of the cardiac nuisculature of children is the rarity of cedema and decided venous congestion, even in these serious forms of acute heart disease.
No effective treatment of malignant endocarditis exists. Hydro therapy and stimulants should always be tried. In any case the treat ment of insufficiency of the cardiac muscle should be begun very early (see p. 527).
Treatment of Acute Benign Endoearditis.—As in pericarditis, a prophylactic treatment of endocarditis in childhood may be men tioned; salicylic preparations should be given for the slightest rheu matic symptoms of children and complaints of pain in the joints and muscles later childhood should never be allowed to pass without attention.
The drug treatment of the disease, after it has developed, is to be restrictecl whenever possible. _Absolute rest ancl the permanent applica tion of cold, the prevention of bodily ancl psychic excitement, nons.tiniu lating diet, an antiphlogistic general regime in eases with fever (without internal antipyretics) with especial attention to hyclrotherapy [cold sponge baths at 25° C. (S7° F.)] suffice for simple cases. When rheumatic attacks also occur, the use of salicylates is indicated, but only long enough to overcome the joint pains and swelling. So, too, digitalis should be administered as sparingly RS possible in the acute endocarditis of childhood. Blisters and cauterization, as recommended by French writers, are superfluous and often injurious procedures. When the heart action is excited, bromides are given, and when the pulse is of high tension, sodium or potassium iodide, in doses of one to three decigrams a day. With decided pains in the chest and attacks of dyspncea in older children, codeine, dionine [1 to 2 cg. (*—ls gr.) daily] or morphine [1 to I cg. gr.) daily] must be administered. Recently the treatment of acute heart affections of children by opium has been w-artnly advocated by Morison.
2. Chronic Endocarditis and Acquired Heart Lesions of Childhood.
The most frequent cause of heart lesions in children is acute endo carditis. Among 47.S children between 2 and 15 years of age observed during fifteen months, Weill found 25 (5 per cent.) with valvular heart
lesions. This condition occurs very rarely before the fifth year but frequently in later childhood, though only half as frequently as in adult age.
Rheumatism plays the principal part in the etiology, leading in children, sometimes without previous symptoms of endocarditis, to chronic changes upon the ostia and valves of the heart. In childhood, doubtless, too, there occurs a chronic primary sclerosis of the valvular endocardium which leads to stenoses of the ostia, believed by Potain and Teissier to be associated with tuberculosis. A certain family pre disposition to chronic mitral endocarclitis cannot be shown. Chronic arteriosclerosis, lead poisoning and diabetes mellitus do not play any part in the occurrence of cardiac lesions in childhood. Only syphilitic affections of the endocardium sometimes leacl to heart lesions in chil dren. In tbe majority of cases chronic endocarditis is the result of an acute enclocarditis which has recovered by cicatrization.
Acquired valvular lesions of the aortic ostium develop almost exclusively in later childhood, though aortic insufficiency, without other cardiac anomaly, with the ductus Botalli closed, showing that the lesion is acquired, has been seen by Seiffert in a child of eighteen months.
Hauser observed in a child of fourteen months true stenocarclia cordis, due to cicatrizing endocarditis at the insertion of the aorta, below the ostium, with totally uninjured valves and consecutive, very considerable hypertrophy of the heart.
Pathologic Anatomy.—No essential differences exist between chronic endocarclitis in children and in later life, except for the especial predilection of the mitral valve in childhood. According to the inves tigations of Steffen and IIochsinger, one affection of the aortic valve occurs to IS mitral lesions in childhood. Great compensatory hyper trophy of the left side of the heart appears much more rapidly in child hood, especially with mitral insufficiency; while dilatation is only ob served after some time and then is always accompanied by- considerable hypertrophy. Hypertrophy and dilatation of the right side of the heart occur only in severe cardiac lesions of children, which have lasted a long time and are accompanied by considerable functional disturbances, excepting lesions of the pulmonary valves, which depend upon congeni tal anomalies chiefly.