The subjective symptoms of insufficiency of the heart muscle are less severe in children than in adults. Painful palpitation, feelings of oppression, piercing pains in the cardiac region are rare symptoms even in advanced cases, while older children, on the contrary, complain of debility and gastro-intestinal disturbances, stomach ache, regurgita tion, loss of appetite, constipation or diarrheea. With chronic cardiac diseases of children symptoms of myasthenia usually appear absolutely outspoken, in contrast to myasthenia of adults in which initial stages, mild often for years, are observed.
Hochsinger considers that insufficiency of the heart tuusele in obese older children has received little attention. It is not as if the accumu lation of fat upon the heart itself would be au obstacle to its contraction, but rather the disproportion between volume and strength of the heart muscle on the one side and the execution of a large amount of work by the heart on the other, winch is made conditional by the heavy body of the child, in that it obstructs respiration by deposits of fat in the abdo men and chest, a condition which, with more violent bodily exertion, may give rise to refusal of the heart to continue.
Treatment.—The treatment of cardiac weakness in children differs tttle from that of adults. Heart tonics are employed on the one hand and on thc other physieal therapeutic methods, both local and general. As regards the latter, cold may be used in the forni of cold coils, ice-bags, heart bottles, a sovereign means for combating accelera tion of the heart and pains and at the sante time a cardiac tonic of the highest rank. Unfortunately these methods of treatment are not always easily adaptable to small children. Prophylactically, too, children with heart disease should be made accustomed to cold, applied to the heart for a half hour several times a day.
In the treatment of insufficiency of the heart muscle in children, whether the subjective symptoms of dyspnoca and cardiac pain or those of hepatic congestion are most prominent should be considered. In the former case narcotic measures cannot be dispens.ed with for a time at least, and it should be noted that dose.s of morphine chosen to suit the age of the child deserve prominence above all other narcotics. Yet morphine should never be given without giving heart tonics at the same tinie. With a combination of sedative and tonic drugs it is fre quently possible to omit the narcotic absolutely for a long time.
Preparations of digitalis take the first place among the heart tonics for children. They are indicated in childhood in all conditions of weak
ness of the cardiac muscle. They first affect the musculature of the left side of the heart, bringing about an invigoration and retardation of the heart contractions, by which the quantity of urine is increased, and the cyanosis and dyspneett are diminished. The indications for the prepa ration of digitalis and the length of time it is to be given should be lhn Red very sharply, on account of the cumulative action of digitalis, more to be feared in childhood even than in later periods of life.
Preparations of digitalis are indicated in all conditions of insuffi ciency of the heart muscle in the course of chronic heart disease and in those acute cardiac affections which am associated with accelerated pulse and diminished blood pressure. The unmethodical administra tion of digitalis in every heart affection is to be combated. Itl con genital heart lesions of infancy, if a communication exists between the ventricles, the administration of digitalis may be directly injurious, because by an increase of pressure in the left ventricle a larger quantity of blood is carried to the right side of the heart and into thc pulmonary circulation, already overworked without that. Congenital heart lesions in children should only be treated with digitalis when symptoms of myasthenia, exceedingly small radial pulse or persistent dyspncea, exist.
In the cardiac affections of children accompanied with myasthenia, one contraindication to the use of digitalis, from its relation to the arterial system, very frequent in later Efe, is almost totally lacking. Since digitalis also has a constricting effiict upon the blood vessels, it should not be given in diseases of the blood vessels. This contraindica tion to digitalis occurs in childhood only with congenital narrowness of the arterial system and in rare case.s of syphilitic disease of the arteries.
Recent pharmacology has furnished two preparations of digitalis which are of especial value in childhood. Golaz' dialyzed digitalis and Cloetta's (figalen. Both preparations have an absolutely reliable and constant action and can be added to milk or other liquid nourishment drop by drop. When the stomach is intolerant, these drugs may ad vantageously be given in small enemata, several times a day. The Cloetta preparation may also be given subcutaneously, besides, but produces slightly painful infiltrations.