As all the infectious diseases may lead to new attacks of endocar ditis a prophylaxis, doubly careful in this respect, is to be employed for children with heart disease.
The choice of occupation for children with heart disease is impor tant. For children of the middle class business comes first; for those of the working class occupations arc to be chosen which are not attended by continued severe bodily exertion and do not cause leading a con stantly sedentary life. They should become barbers, glaziers or uphol sterers.
House and clothing need attention to prevent the recurrence of rheumatism. Dry airy apartments, in the sunshine at least part of the day, are of importance for children with heart disease; their clothing should be warm during winter, hut heavy goods should be avoided. In summer all those materials which imbibe modsture should be avoided (silk and linen). Cassel advises woolen clothes for children with heart disease for at least several years after tbe last attack of rheumatism.
Balneotherapy in the form of slight hydrotherapeutie measures, partial sponges at from 20° to 16° C. (68° to 60° F.); half baths from 26° C. (7S° P.) down; cold water tubes on the heart region tuice or three times daily for an hour, and carbonic acid baths, either natural at Nauheim or Franzensbad, or artificial at home, assists the prophy lactic and dietetic treatments.
For cardiac weakness, with loss or compensation, reference should be made to the principles explained later, on page 527.
MYOCARDITIs Pathologic childhood as in all periods of life, parenchymatous and interstitial myocarditis are distinguished anatomi cally. Parenchymatous processes often appear acutely in the course of severe infectious diseases (diphtheria, typhoid fever. scarlet fever, whooping-cough) in which, as the final stage anatomically, fatty degen eration (yellow atrophy) occurs. In the acute parenchymatous processes the muscular tissue of the transverse bands appears to be lost, the muscle fibres are filled utith a finely granular mass, show hyaline degeneration or are broken into pieces and in many places replaced by fatty drop lets. Pore parenchymatous rayocarditis, without affection of the in terstitial tissue, has been noted in childhood by Bouchut, Barjon, and Janot. In the majority of cases, however, primary- parenchymatous myocarditis is associated with interstitial changes also.
The heart in parenchymatous myocarditis is soft, flaccid, pale, pliable and crossed by yellow stripes or Inemorrhages in the region of the apex.
Parenchymatous affections of the heart muscle in childhood very frequently accompany all possible infections and are equally a8 fre quent in infancy as in later childhood. Sudden death during many of the infectious diseases of children depends upon parenchymatous inyocarditis.
Much more rare in childhood are interstitial myocarditis processes which may- take an acute or chronic course. Acute interstitial inflam mations of the heart muscle arise in children either by continuation of inflammatory processes to the pericardium or endocardium, or emboli cally-, by the introduction of microorganisms into the blood vessels of the myocardiurn. The most severe form of interstitial myocarditis is purulent myocarditis which occurs in the septic forms of scarlet fever, measles and diphtheria, and in osteomyelitis of children also, which may lead to abscess formation in the wall of the heart and in the septum, to perforation into the cardiac cavity and pericardium anci to the de velopment of acute aneurysms of the heart.
In interstitial inyocarclitis the cellular tissue between the muscle fibres shows cellular, i.e., purulent, infiltration either circumscribed to certain areas or diffuse. In the chronic forms callosities are frequently found which may lead to chronic aneurysms of the heart and sudden rupture. Here also belong the syphilitic callosities, gummata in the later stage of hereditary syphilis, and scattered cases of tuberculous myocardi tis.
The mixed form of inyocarditis is most frequent, affecting all the tissues composing the yvall of the heart. This may be circumscribed or diffuse. In the latter the muscle fibres, connective tissue, cardiac nerves and blood vessels of the cardiac wall show inflammatory changes. The worst cases clinically are the result. In rliphtheria especially a peri neuritis of the cardiac nerves has been found very frequently. Often the small vessels have been closed by vegetation of the intima or by thrombosis, causing hamorrhages in the vicinity.