GENERAL SYMPTOMATOLOGY AND DIAGNOSIS The symptomatology of heart diseases in childhood is somewhat simpler than in later life. Secondary conditions in remote portions of the body, such as congestion of the parenchymatous organs or dropsy, are almost entirely absent in the heart affections of early childhood, because of the extraordinary tolerance of the child's heart. Recovery from acquired endocarditis is also a much more frequent result in child hood. Auscultatory signs play the chief part in the .symptomatology. Congenital as well as acquired heart lesions may exist in children a long time without any change in the percussion dulness.
The most important auscultatory changes in the child's heart are the murmurs, which are more characteristic than in adults. While the sante value in diagnosis is attached to exocardial murmurs in children as in adults, endocardial murmurs show a varying relation, in that infancy is almost entirely free from the so-called accidental heart mur murs. In the second and third years of life, too, so-called amemic mur murs are very rare. ITochsinger, Soltmann, Delahost and Romberg have accepted the complete absence of accidental (so-called amemic) heart murmurs in the first years of life, yet this is contradicted by Thiemich, von Starck, Abelmann, Rheiner, Methling, Jacobi, Heubner, Swarsenski and Looft, who concede only their great rarity in early childhood.
The systolic murmurs by far outnumber diastolic and presystolic murmurs in frequency; besides systolic murmurs are very often only added to the. first heart sound, while diastolic murmurs almost always replace the second heart sound wholly. The temporary concealment of heart murmurs by accelerated respiration and rAles is much more frequent in children than in adults. On the contrary, temporary dis appearance and return of murmurs (disappearance when at rest, recur rence with exertion) are only noticed in children exceptionally. Cardiac murmurs as the result of acquired heart affections are heard with more difficulty in early childhood than in older children and adults; while in congenital heart lesions very loud murmurs have already been ob served, even in infancy-. Only the latter are well transmitted to the back. Thrills, which are palpable heart murmurs, are more. apt to
accompany the heart action of a child than that of an adult, because the child's thin chest wall oscillates more easily. Heart murmurs dependent upon acquired affections appear chiefly at the mitral valve; those caused by congenital lesions more especially at the pulmonary ostium. In the former the point of maximum intensity of the mur murs will be at the apex; in the 'Atter, in the second intercostal space to the left of the sternum. Not always, as is the case occasionally in congenital cardiac anomalies, is the point of maximum intensity the same as the point of origin of the murmur, for several murmur-producing causes may be located at different places within the heart, and by trans mission to one spot, produce an especially loud acoustic impression there. The point of orig,in of a heart murmur can sometimes be deter mined by observing the transmission of the murmur to the back. If, in little children, murmurs are transmitted to the lower left side of the back better than to the upper, then most probably the murmur is due to a change at the venous ostia. When the opposite is true, the origin of the 111111111Ur with approximate certainty is at the base of the heart, i.e., at one of the arterial ostia.
Organic Endocardial Murmurs.—These occur in acquired con genital heart lesions of children. The acquired heart diseases are in flammatory diseases of the endocardium and acute dilatation 'of the heart, which lead to relative insufficiency of the venous valvular appa ratus. The timbre of the murmur is as a rule higher and shriller in chil dren than in adults and the murmur is transmitted further over the anterior chest wall.
The murmurs of acute dilatation of the heart in children, occurring sometimes in the course of scarlatinal nephritis, are accompanied by dyspncea, pain in the chest and a tendency to collapse. The cardiac dulness becomes very much increased laterally, the pulse very weak and frequent. In acute endocarditis, on the contrary, at the tirne of the first appearance of murmurs, signs of dilatation of the heart are usually absent, as are the other severe accessory symptonis just mentioned.