Diagnosis.—The diagnosis is divided into two parts, the general diagnosis of a cardiac lesion and the recognition of the seat of the lesion. As functional disturbances are lacking in half of the cases, the consid eration of the physical signs in children is of double importance. (For the general differential diagnosis between congenital and acquired heart leons, see page 459.) The diagnosis of the addition of chronic endocar ditis to congenital disturbances in the development of the heart, a fre quent occurrence, can be niade sometimes from the changes or modi fications of the physical signs in conjunction with an increase of the subjective symptoms.
Mitral I ',sufficiency. —This, the most frequent canliac lesion of childhood, is characterized by the development of hypertrophy of the left side of the heart, especially of the left auricle, in conjunction with a systolic murmur with its point of maximum intensity at the apex. The nuirmur is transmitted to the left axilla and to the back. Pure forms of this cardiac lesion are often seen for a long time 111 childhood.
11Pitral Stenosis.—This frequently accompanies mitral insuffi ciency in later childhood, and is characterized by a diastolic, sometimes split murmur at the apex. In childhood especially the transition of a mitral insufficiency into a pure mitral stenosis has been observed, with the disappearance of the systolic and the substitution of a diastolic murmur at the apex. It is, however, a well known fact, corroborated by observations during childhood especially, that diastolic murmurs may be absolutely absent in mitral stenosis (Jacobi).
Aortic Stenosis.—In these acquired heart lesions, in childhood an inflammatory adhesion of two or all of the semilunar valves is usually found. This affection is found only in later childhood and very rarely alone, being almost always associated with inability of the aortic valves to close. The physical signs are a rough systolic murmur over the aortic area and hypertrophy of the left ventricle.
Aortic Insufficiency. —This is always combined with stenosis of the aortic ostium and is the gravest form of heart lesion in childhood. Children with aortic insufficiency rarely live beyond puberty. Sudden death not rarely occurs. The aortic tip of the initral valve is almost always affected also by the chronic inflammation so that, when this has lasted some time, a combined lesion results, with an unfavorable prog nosis. The pathognomonic sign of aortic insufficiency is a diastolic murmur with its point of maximum intensity in the second intercostal space to the right of the sternum, which is transmitted downward to the xipboid process, but is also heard. though weaker, toward the neck.
The valvular lesions and ostittm stenoses of the right side of the heart have been described with the congenital heart lesions, since they originate for the most part during fcetal life. It should be noted, how ever, that tricuspid insufficiency, which produces a systolic, usually whist ling murmur over the xiphoid cartilage, is sometimes joined to mitral insufficiencyin the .stage of lossof compensation, as a relative insufficiency.
Course.—A peculiarity of juvenile heart lesions, especially of mitral insufficiency, consists in their long latency, their extraordinary compensatory ability and their slight mortality during childhood. In aortic insufficiency, the situation is less favorable. Recovery from well developed cardiac lesions has heen repeatedly noted in children, even after the lesion has lasted for years (Roger, Trousseau, de Gassicourt, 6anne, Andrew, Gerhardt, Ovazza, Hochsinger). In the majority of cases severe disturbances of compensation, with cedema, diminished secretion of urine, pulmonary catarrh from congestion and the production of in farcts, only develop after puberty. But all these symptoms occur in childhood also in complicated lesions, with frequent recurrence of endo carditis, although they are rare before the end of the fourth year.
Marian considered mitral endocarditis of childhood so benign that he always blamed the appearance of insufficiency of the cardiac muscle, With the clinically established symptom-complex of antral insuffi ciency, upon some accompanying affection. In this relation latent pericardial adhesion is first to be noted, and secondly the presence of congenital heart lesions also.
Treatment.—The treatment of acquired valvular heart lesions of childhood differs little from that employmd in later life, as the children suffering from acquired lesions almost always belong to later childhood. A certain hygienic care of those children who show no real functional disturbances is of importance. All overexertion of the heart from boffily or mental demands is to be avoided. Athletic sports and swimming exercises are forbidden, but on the contrary regular movements of the, muscles, by walking in the open air, are advised. Incorrect carriage of the body should be corrected. Nourishment should be abundant, without too much liquid and with DO acrid substances. Tea, coffee, alcohol and tobacco must be absolutely forbidden.