With the Compliments of the Author. 
THE TREATMENT 
•OF 
endocardial complications 
IN THE 
DISEASES OF CHILDREN. 
BY 
WAI. W. VAN BAUN, M.D., 
PHILADELPHIA, PA. 
Reprinted from the Hahnemannian Monthly, August, 1890. THE TREATMENT 
OF 
ENDOCARDIAL COMPLICATIONS 
IN THE 
DISEASES OF CHILDREN. 
BY 
WILLIAM W. VAN BAUN, M.D., PHILADELPHIA, PA. 
The intimate association of rheumatic arthritis, chorea and endo- 
carditis, together with the well-established fact that endocarditis is 
not a primary or idiopathic condition, if we omit direct injury as a 
cause, gives to the subject of the preventive and remedial treatment 
of endocardial complications a far-reaching importance. In consid- 
ering the diseases with which an acute cardiac inflammation is apt to 
be associated, rheumatism naturally stands out in bold relief. So 
well is this relationship understood in pronounced cases, that the at- 
tendant is at once on his guard for the cardiac attack. The impor- 
tant point, however, is the recognition of the danger of the heart in 
cases in which the symptoms are not well defined or are altogether 
wanting. The successful handling of endocarditis depends on its 
early discovery and treatment; it is, therefore, essential always to be 
on the alert for the possible complication. For example, children 
suffering from slight attacks of fever, with obscure pains, should sug- 
gest to our minds two good points of routine practice ; first, to make 
frequent examinations of the heart with the stethoscope, and secondly, 
to search carefully for joint tenderness, remembering that in chubby 
children redness and swelling of the limbs are usually absent. 
Again, in children of rheumatic parentage, we are not to lose sight 
of the possible rheumatic origin of the attacks of pains in the legs, 
with or without pyrexia, which are so frequent in childhood, and 
also in such diseases as tonsillitis, pleurisy and pneumonia, even if 2 
the leg pains are absent. If such cases are dependent on latent 
rheumatism the condition of the heart is in grave peril. It is in just 
such a state of affairs that we are to look for an explanation of the 
cause for the frequent existence of mitral stenosis in young women, 
and we can easily convince ourselves that the condition is the result 
of an undiscovered rheumatic endocarditis in early youth. This as- 
sociation of chorea, rheumatism and endocarditis has of late been 
greatly dwelt upon. Statistics show that the cases of chorea with 
endocarditis as a complication are usually those coupled with rheu- 
matism, the natural inference being that the endocarditis of chorea is 
of a rheumatic origin. But it is an admitted fact that there are cases 
of chorea with acute cardiac inflammation as a complication, where a 
rheumatic history cannot be traced. Consequently we are to watch 
the heart of every case of chorea with the greatest care. Heart in- 
flammation is liable to occur in scarlet fever, diphtheria, measles, 
tonsillitis, septicaemia and purpura rheumatica. In all of these dis- 
eases, especially in children, the endocardial inflammation creeps on 
insidiously, and is likely to be sub-acute. If there be no secondary 
pericarditis or myocarditis it may run its course without attracting 
attention, there being no praecordial pain, palpitation, dyspnoea or 
distress of any kind, and, on auscultation, it may be impossible to 
demonstrate the presence of a bruit, and yet the subsequent history 
of such children will show the development of a serious valve lesion 
that can be accounted for only on the ground of an unrecognized 
endocarditis. The knowledge of such cases must make us suspicious 
of cardiac danger in all cases of rheumatism, no matter how trivial 
the symptoms. I coincide with the opinion that, in the majority of 
cases, chorea is simply an expression of a rheumatic diathesis. A 
careful examination of the hearts of children complaining of slight 
rheumatism, scarlatina, chorea, erythema, tonsillitis, nephritis, pyae- 
mia, eic., where the fever and other symptoms are possibly only slight 
may reveal an unexpected valvular murmur, the early recognition of 
which, leading to proper treatment, will save the little sufferer from 
a wrecked and stranded existence. In other words, we are not to 
wait for patients to complain of heart symptoms. Expectancy and 
constant watchfulness will enable inspection alone to warn us of the 
earliest cardiac involvement. The expression of the face, the in- 
creased difficulty in breathing, no matter how slight, the working of 
the alse nasi, the posture in bed, the restlessness, etc., all indicate the 
oncome of the endocardial complication. In taking up for consider- 
ation the treatment of rheumatic endocarditis, the chief clinical fea- 3 
ture brought to our attention is its tendency to repeatedly relapse and 
recur. Under careful treatment the temperature may fall to normal, 
the restlessness disappear and all the symptoms abate, the child, seem- 
ingly, convalescing splendidly. Suddenly, without cause, or from 
causes apparently in themselves trifling, the inflammation revives 
with all its old vigor and danger. Thus the condition may run a most 
persistent and protracted course. This striking feature in the clinical 
history of endocarditis shows the remarkable obstinacy of the rheu- 
matic poison, and leads us to the first great essential point in our 
treatment; that is, the necessity of persistent effort-the patient 
must be kept under medical inspection for a long time. Any half- 
hearted management will lead to disastrous results. The peculiar 
susceptibility of children to impressions is very apt to be overlooked. 
All of us can probably recall cases of endocardial complication appa- 
rently on the high road to recovery under careful treatment, all 
routed and upset, the patient worse than in the beginning, the cause 
being a simple change in the diet, an error in the temperature of the 
room, the visit of a playfellow, the parting of a nurse, an exciting 
story, a sudden fright and similar circumstances. In a recent case I 
found a rise of temperature of four degrees, a return of rheumatoid 
pains, oppression in breathing, etc., in less than four hours, all of 
which was attributed to a sleeping convalescent being awakened in 
terror, in the dead of night, by the rumbling and clattering of racing 
fire-engines. Any of these causes may, in susceptible childhood, be 
the means of bringing our best effort to nought and our patient a 
serious relapse, besides straining the relationship between the physi- 
cian and family. The latter, not being able to appreciate the reason 
of such repeated relapses, it becomes the duty of the physician, both 
to himself and the family, to explain in the very beginning of the 
case this disposition to recurrence, and to insist upon the most scru- 
pulous care and persistent effort in behalf of the little patient long 
after all apparent signs of the trouble have disappeared. 
Our first care will be the prevention of the cardiac complication, 
and the greatest prophylactic at our command is heart rest. In those 
cases where we suspect this liability we are to use every endeavor to 
cut short the underlying diseased condition. If it be of rheumatic 
origin the endocarditis is likely to appear during the first week. If 
the patient can be piloted, by persistent and careful effort, through 
the violence of the first week of the rheumatic storm, the complica- 
tion will probably be avoided. The means to accomplish this end 
are, first, the remedy best suited to the individual case, assisted by a 4 
competent and vigilant nurse, the avoidance of chill, which is es- 
pecially apt to occur, and, secondly, a rigidly fluid diet, richly 
nutritious, but non-stimulating. 
When the complication-endocardial inflammation-really exists, 
we are still to insist on rest-absolute rest-bodily and mental, kept 
up long after all signs of endocarditis have disappeared. Exertion 
of all kind increases the action and force of the heart and favors the 
development of inflammation; while mental excitement will surely 
give rise to increased cardiac action. The necessity of rest cannot 
be too much emphasized. Rest in bed means the restriction of mus- 
cular effort in every possible way. The patient is not to use his 
hands where it can be avoided; the holding of a picture-book is 
especially objectionable. The nurse should anticipate all demands 
and supply all requirements. The feeding is to be accomplished 
with the aid of the invalid's cup, or the bent tubes; the bowels, 
which must be kept regular, and the bladder are to be evacuated 
with the use of the bed-pan and urinal; the personal comfort of the 
patient is to be most zealously attended to; this will tax the best 
judgment and ingenuity of the physician, nurse and parents. The 
diverting the mind of a pampered child from an ever-returning 
craving for some simple but harmful article of solid diet, which 
must be resisted, no matter how trying to the parents, and must be 
done in a way that will calm and not excite the patient, will often- 
times require of the attendants the attributes of an angel. A meal 
of solid food will excite the circulation, quicken the cardiac action 
and act banefully on the inflamed lining membrane of the heart. 
Stimulants are only to be used where they are demanded by cardiac 
failure, and then with the greatest caution. A characteristic feature 
of the indefinite relapsing form of endocardial complication, which 
drags along week after week, month after month, is a progressive' 
anaemia, sometimes associated with wasting. This tendency will be' 
difficult to overcome. The internal treatment will naturally be the 
remedy that covers the totality of the symptoms of the individual 
patient. 
In rheumatic conditions aconite has served me well, in the begin- 
ning, in the state of hyperaemia preceding the valve changes, the 
pulse being small, hard and quick, with pains of a sharp, pricking 
character in the praecordium, associated with faintness, oppression, 
together with tumultuous action of the heart, causing anxiety and 
fear of death. If aconite does not speedily relieve, spigelia has been 
almost a specific in endocarditis. It corresponds to the disease; the 5 
pains are severe, shooting or stabbing in character, with a distress- 
ing oppression in the chest, the least motion producing exhaustion 
and suffocation. The palpitation at times is very violent, the move- 
ment of the chest-wall being quite perceptible. The patient cannot 
lie down. If the palpitation persists after the use of spigelia, spon- 
gia has proved to be a valuable remedy; it also follows aconite well, 
it comes in after the exudation of fibrine and tends to limit the de- 
posit. Veratrum vir. is useful in cases with violent congestion, 
pain and intense force of circulation. Headache of an acute throb- 
bing nature, without delirium. With rest, an absolute liquid diet, 
and these four remedies I have usually been able to abate the inflam- 
matory action and shorten the duration of an attack. Kali hydri- 
odicum is a useful remedy in the relapsing endocarditis of rheumatic 
origin, where there has been an eruption of subcutaneous fibrous 
nodules. Bryonia will be the remedy for the complication when it 
is secondary to pleurisy or pneumonia. Arsenicum is indicated 
during or after the suppression of measles or scarlatina, where we 
have the characteristic restlessness and agony of the drug, with ting- 
ling in the fingers, especially of the left hand, together with dysp- 
noea. Phosphorus is a neglected remedy in endocarditis; it is of 
particular value where the endocardial complication arises during 
the course of an acute rheumatism, in rapidly-growing children who 
are excessively susceptible to every impression, be it pleasant or 
otherwise. When associated with chorea I rely on arsenicum, cimi- 
cifuga, mygale, phosphorus and verat. vir. If the complication is 
recognized early I depend upon aconite, ferrum phos., spongia, 
spigelia, bryonia or phosphorus, whereas, if the disease is advanced, 
then dependence is placed on such remedies as lachesis, hydrocyanic 
acid or arsenicum. 
When the primary disease, such as rheumatism, chorea, scarla- 
tina, etc., has subsided and the restoration of the various functions 
indicate that convalescence is well established, I feel that I am enter- 
ing upon the most difficult stage of the treatment. It is so hard to 
bolster up the moral courage of a fond mother to the point of resist- 
ance of the oft-repeated pleadings of a loved little one " to get up/' 
" hold me in your lap just a little while," and the thousand and one 
other things that suggest themselves to the active brain of our frail 
physique city children, with the highly developed and over-wrought 
nervous systems. We are never to lose sight of the recently in- 
flamed endocardium, and that in all probability it is still in a con- 
dition of great physical weakness and the seat of new cell growth. 6 
If we turn a dull ear to the mutterings of attendants and persist in 
our demands, we will, in the majority of cases, be able to impress 
on our families the necessity, if not the reason, of a most jealous 
avoidance of actual exertion for weeks, and the need of a most care- 
ful and gradual return to exercise. If we succeed we will save our 
patients from results that would otherwise be disastrous, and while 
we may feel that our best efforts have not been appreciated, we can 
console ourselves with the conscious rectitude of our purpose.