THE NATURE AND FREQUENCY OF HEART AFFECTIONS IN cuthifittam The numerous changes the musculature and valvular apparatus of the heart which are caused by atheroina of the arteries, the use of alcohol and tobacco, mental and physical overwork, are almost entirely absent in the first years of life. It results necessarily, therefore, that acquired affections of the arterial ostia in the form of valvular stenosis and insufficiency, or primary myocardial affections must be rare in childhood. Almost without exception the cause of such changes in childhood is pericarditis or endocarditis as a result of the infectious diseases, which soon produce acute, subacute or chronic changes in the valves, ostia and myocardium: but these are not. among the very fre quent diseases of childhood. If we add to thi,s the well-known fact that acquired heart affections are but rarely found at the ostia of the right side of the heart, and then only as remains of fcetal inflamma tory processes, complicated by recrudescent endocarditis, it is easily understood that the occurrence of acquired heart disease is decidedly restricted in early childhood, being limited entirely to inflammatory changes of the left venous ostium.
Samson, from his observations, considers the frequency of heart diseases in childhood as 3 is to 500 (i per cent.). Among 227 children treated for severe internal affections resulting from the infectious dis eases, 3S had cardiac disease (16.7 per cent.).
Samson divided 131 cases of heart affections in children (100 of them his own observations) into groups according to age, as follows: In this table 24 cases occurred in the first five years of life, 18.3 per cent. This includes both children with cong,enital and acquired heart lesion. Cassel found, among 20,000 sick children, 107, about per cent., with heart affections (the seXes heing equally divided), of which 26 were congenital.
The most important clinical signs for differentiating between con genital and acgvired heart affections in children are the following: 1. Loud, harsh and musical heart rourniurs, with normal or imma
terially increased dulness, occur in small children with congenital lesions only. Acquired heart atTections, arising from inflammation, with very loud heart murmurs, without exception show in small chil dren large areas of dulness also. With combined congenital malforma tions, the cardiac li.ypertrophy may be increased by the mutual relations between the separate anomalies.
2. Heart murmurs with large areas of cardiac dulness and weak apex-beat point to congenital changes in small children. Dulness is increased on the right side of the heart, while the left side is but slightly changed. Acquired endocarditis of children is accompanied by accent uation of the apex-beat since the left side of the heart is most affected; only later is dilatation of the right side added, without changing the increased strength of the apex-beat.
3. The absolute absence of murmurs at the apex, when they are clearly audible over the ventricles and at the pulmonary area, is always of great value in clifferential diagnosis, pointing to a defective septum or pulmonary stenosis rather than to acquired endocarditis.
4. An abnormally weak second sound at the pulmonary area and a distinct systolic murmur in early childhood are symptoms which can only be explained by congenital pulmonary stenosis, and are therefore not to be undervalued in differential diagnosis.
5. The absence of a palpable thrill, in spite of a very loud murmur, audible over the entire precordial region, occurs almost only with congenital abnormal openings in the septum and therefore points against an acquired heart affection.
6. Loud, vibrating, systolic murmurs, with the point of maximum intensity in the upper third of the sternum, without symptoms of marked hypertrophy on the part of the left ventricle, are very important signs in the diagnosis of persistent ductus Botalli; and they cannot be explained by endocarditis of the aortic valves.