Inflammation of the Heart (Carditis)

Rheumatic Infection of the Heart in Childhood

Inflammation, usually of rheumatic origin, affects any or all of the three main parts of the heart - the inner lining or endocardium, the main muscle of the heart chambers or myocardium, and the outer sac or pericardium, which covers the heart. Rheumatic infection is the direct cause of many cases of heart disease under the age of 40.

In adult life a typical attack of rheumatism causes acute arthritis, with pain and swelling of the joints. In children, however, although the joint symptoms may be prominent, they may be vague or even absent, and the rheumatism may appear in the form of various skin eruptions, pains in the legs, or ‘growing pains’, ‘rheumatic nodules’ or small hard lumps the size of peas in the scalp and behind the knuckles and elbows, sore throat from tonsillitis, acid sweats, and chorea. Rheumatism in children is generally stealthy in onset, with complete absence of symptoms for a time. When they do appear, in the form of pallor, fatigue, loss of appetite and a failure to put on weight, they are apt to be mild, and apparently of no great significance so that they may be overlooked. In spite of this gradual onset, however, the heart damage is no less than in the highly feverish forms with typical painful swollen joints.

Any child with 'growing pains', frequent sore throats, chorea, or rheumatic nodules behind the scalp and elbows should be protected from cold and damp, and the heart should be carefully examined.

Diseases of the Heart Lining (Endocarditis)

Endocarditis is an inflammation of the lining membrane of the heart. In the great majority of cases the inflammation chiefly affects the valves, while some inflammation of the heart muscle (myocarditis) is generally also present.

Acute Simple Endocardttis

Causes.

Acute simple endocarditis occurs most commonly in childhood and adolescence, and in most cases is due to rheumatic infection, though it is occasionally caused by scarlet fever, pneumonia, typhoid fever and smallpox.

Symptoms.

Besides the general symptoms of the main disease, usually rheumatism or rheumatic fever, there may be shortness of breath, palpitation and discomfort or pain in the heart, with an increase of fever, and a pulse rate quicker than normal. The valves become swollen, and covered with small warty vegetations, and finally scarred, contracted and deformed.

Treatment.

This aims at preventing as far as possible any permanent damage to the heart. Rest in bed for three months is essential, during which time the patient should not be allowed to do anything for himself; some further months of partial rest should follow, and a gradual attempt should be made at easy walking exercises. If at any stage any fresh symptoms appear, the amount of activity should be reduced. Children who have had an attack of acute endocarditis should be sent to a convalescent home with teaching facilities for six to eighteen months following the period of rest.

The diet should be mainly of milk, diluted with water or mineral water, and so long as there is fever, nothing should be added except whey, peptonised milk or barley water. As the fever subsides, cereals, vegetable soups and chocolate may be added. Meat should be reserved for convalescence, and tea and coffee are best withheld.

At the outset of acute rheumatic endocarditis in an adult one gramme of sodium salicylate, made into a mixture which has been flavoured with peppermint, should be given every two hours during the day and every four hours at night. As the symptoms subside, these quantities may be given less frequently. The dosage for a child of 12 years should be one-half of that for an adult.

Pencillin may be given in short courses if there is simultaneous infection of the tonsils.

Acute Bacterial Endocarditis;

Sub-acute Bacterial Endocarditis

Cause.

The acute form is an uncommon but very serious disease of the heart. It is caused by a general blood infection with various micro-organisms-pneumococci, staphylococci, gonococci.

The subacute form usually follows an attack of rheumatism or other fever with endocarditis. After several years; the gradually increasing weakness of the damaged valves permits the invasion of bacteria - usually streptococci. Once infection develops in the vegetations of the heart valves, a condition of chronic blood poisoning results. Small pieces (emboli) of the vegetations may break off from the valves and, after being carried by the bloodstream, may block narrow blood vessels in the kidneys, spleen, retinx, brain, or limbs, with resultant pain, blindness, paralysis of one side, or sometimes brain haemorrhage.

Symptoms.

In subacute bacterial endocarditis the onset may be sudden, with the general symptoms of an acute feverish illness and pains in the joints. The condition fails to respond, however, to treatment with sodium salicylate, and an irregular fever with repeated shivering fits (or rigors) occurs. More commonly, the onset is gradual, with slowly increasing weakness, sweats and anaemia. The patient becomes increasingly anaemic with a pale coffee-coloured complexion, and continues to lose weight. Petechial haemorrhages appear under the skin.

Treatment.

General treatment consists of fresh air and good food, with extra vitamins and iron for the anaemia. Penicillin or another appropriate antibiotic is now used in large doses daily, often continued for a few weeks, and with this treatment the disease has a recovery rate of over 90 per cent.

Chronic Endocarditis

Chronic endocarditis is generally a sequel to the simple rheumatic type. There are, however, two other varieties, both of which are more common in men, and which appear in later life. The first of these is associated with arteriosclerosis, or hardening of the arteries. The second is the result of syphilis and generally begins in middle life.

Mitral Stenosis (narrowing of the mitral valve).

This, as already mentioned, is usually due to a previous attack of acute simple endocarditis. The two valve leaves become partly fused together, so that the opening is made much smaller. The blood is thus hindered in its passage onwards, and becomes congested in the organs behind the valve, that is, in the left atrium and the lungs; this causes shortness of breath on exertion, cough with blood-stained sputum, and bronchitis; there is usually an associated blueness of the cheeks, lips, tips of the ears and of the finger nails. Embolism is common.

Mitral Incompetence (leaking of the mitral valve).

The most common cause of a damaged mitral valve is the weakening due to an attack of acute simple endocarditis. Incompetence of the mitral valve may also be due to a stretching of the valve after acute fevers, anaemia, disease of the aortic valve and high blood pressure. Regurgitation of the blood-stream may then occur backwards through the valvular opening because the valve fails to close. Incompetence of this type is known as functional. In organic mitral incompetence there may be no symptoms. If present, they resemble those of mitral stenosis, which is generally also present.

Aortic Incompetence (leaking of the aortic valve).

Aortic incompetence is most commonly found in middle or later life and in males. It is often due to a previous attack of acute simple endocarditis or rheumatic fever, although syphilis, which usually causes symptoms between 15 and 25 years after the primary syphilitic infection, is a fairly common cause. Degeneration of the aortic valve in old age is usually associated with general hardening of the arteries. Rupture of a valve segment may very occasionally be caused by sudden physical overstrain.

Symptoms.

The symptoms are often latent for many years, the commonest and the earliest being shortness of breath on exertion. Further symptoms which appear depend upon a reduced supply of blood to various parts of the body. Thus, anaemia of the brain occurs. There is giddiness and faintness when the posture is changed. Pallor of the face is often associated with anaemia. Sudden death is another likely occurrence, and is more common in this than in any other form of valvular disease. Aortic incompetence is thus one of the most serious forms of heart disease, particularly if due to syphilitic infection. In cases of aortic incompetence a blood test should always be done (Kahn or Wassermann Test). The result will generally be positive in cases which are due to syphilis.

Surgical Treatment.

Operative mortality is high but the prognosis, too, is grave. The damage in the stenosed aorta varies greatly in every case and consequently the results of operation vary.

Diseases of the Heart Muscle (Myocarditis)

Acute Myocarditis

Causes.

In most cases, inflammation of the heart muscle or acute myocarditis is caused by acute rheumatic infection, when it is usually associated with acute rheumatic endocarditis, and sometimes with pericarditis. Other causes are diphtheria, influenza, pneumonia, smallpox and typhoid fever. The inflammation of the heart muscle may subside completely, the heart returning to normal, or there may be some permanent residual damage.

Symptoms.

The onset may be gradual with vague symptoms, such as shortness of breath, palpitation and discomfort or pain in the heart. The pulse is fast and feeble. In severe cases, with threatened heart failure, there may also be pallor, restlessness, faintness, vomiting without apparent cause, and coldness of the skin. Sudden death is particularly likely to occur in diphtheritic myocarditis, even when the patient may be considered to be convalescent.

Treatment.

The treatment is the same as for acute simple endocarditis, except that the period of convalescence is not so long. The patient should always be under medical supervision. In severe cases with collapse, the following measures should be adopted. All pillows should be removed and the patient's head lowered, the foot of the bed being raised one to two feet. A firm binder should be applied to the abdomen and the patient kept warm and quiet. An injection of aminophylline (Cardophylin) should be given. Alternatively, nikethamide (Coramine), or leptazol (Cardiazol) may be given by injection. If vomiting is severe, a 5 per cent solution of glucose in warm normal saline (one level teaspoonful of salt to the pint of water) should be given by the rectum (one to two pints). Oxygen may be required.

Chronic Myocarditis

In fibrosis of the heart muscle, or chronic myocarditis, the heart muscle fibres are partly replaced by scar tissue, and the heart is consequently weakened. It is more common in men in late middle life and old age, and usually follows acute rheumatic disease. When it is due to arteriosclerosis it is known as senile heart.

Symptoms.

These are gradual in onset, and usually appear first on exertion (tired heart). The most common are shortness of breath and fatigue, and occasionally there is palpitation and discomfort or pain in the heart. The pulse is fast, and there is usually some enlargement of the heart. Chronic myocardial disease is overlooked more frequently than any other disorder of the heart. Examination by X-ray and by electrocardiogram may be of great value in diagnosis. The disease tends to be progressive and generally leads to congestive heart failure.

Treatment of the Senile Heart.

It is important to remember that prolonged rest in bed for elderly people may lead to congestion of the bases of the lungs, with resultant infection and bouts of coughing. Complete rest should therefore be limited to the minimum period compatible with improvement. Diet in the aged presents its own problems, but in general the secret of success is to be found in moderation. All invalids and particularly elderly people should have their principal meal in the middle of the day. It should be as dry as possible, thus eliminating the tendency to flatulence. A rest in the afternoon and a light meal in the evening will often be followed by a long night's rest. Hot milk, or a little diluted whisky taken some time before retiring may encourage sleep. Much insomnia and restlessness can be prevented by having the bed alongside an open window, and fresh air, as distinct from draughts, should be made freely available.

Enlargement of the Heart

Enlargement of the heart may be due to hypertrophy, or increase of its muscle, with thickening of its walls; or to enlargement and dilatation of its cavities; or, as is usually the case, to both of these conditions together.

Hypertrophy of Heart Muscle.

The presence of increased muscle shows that the heart is continuously working under an extra strain. Any condition which hinders the passage of blood through the body, such as hardening of the arteries with high blood pressure, causes the heart to work harder. The increase of growth of the muscle fibres is produced by an increase in their muscular action, just as the blacksmith's arm is more muscular by exertion. For an overgrowth of the muscle to take place, a good blood supply is essential. Thus it can occur more readily in young people than in the aged. Dilatation, or enlargement of the heart cavities, may be acute or chronic. Acute dilatation may occur in acute myocarditis from infectious diseases such as rheumatic fever, diphtheria, influenza, pneumonia, smallpox and typhoid. It may also occur in atrial fibrillation and, rarely, as a result of excessive physical exertion in persons who are out of training (primary heart strain). Chronic dilatation is present together with hypertrophy in most cases of chronic heart disease, and may be compensatory in cases of chronic valvular disease, allowing the ventricles to accommodate a greater quantity of blood for expulsion with each heart beat. In cases of regurgitation through the heart valves, the dilatation thus allows an approximately normal quantity of blood to be passed onwards with each heart beat. Dilatation may also be associated with chronic heart failure, which brings about a lack of tone in the heart muscle. As the dilatation progresses, the amount of blood contained in the heart chambers becomes gradually increased, and the organ assumes a globular form.

Signs.

When dilatation is associated with heart failure the pulse may be faster and weaker, and the blood pressure lower than normal. The enlargement of the heart may by recognised by X-ray examination.

Diseases of the Heart Sac, or Pericardium

The heart sac encloses the heart, and consists of two membranous layers, which are movable one upon the other. The inner layer is closely applied to the outer surface of the heart. Pericarditis, or inflammation of the heart sac, may be either acute or chronic.

Acute Pericardifis

This may be either dry, or accompanied by a liquid effusion between the outer and inner layers of the pericardium. In pericarditis with effusion, the liquid exudate, which may be clear, purulent or blood-stained, may actually distend the pericardial sac and produce pressure upon the heart and the surrounding structures.

Causes.

Acute pericarditis occurs most commonly in young adults, and is generally due to rheumatic infection. Other less common causes are acute infectious diseases such as pneumonia, septic infections, and occasionally gonorrhoea. It may occur also towards the end of chronic diseases such as Bright's disease and tuberculosis.

Symptoms.

In acute dry pericarditis the symptoms may be slight or absent, but usually there is some fever and pain in the chest. The pain may be felt over the heart, or referred to the left shoulder, the left shoulder-blade, the neck or the upper abdomen. It may be made worse by deep breathing or coughing, or by pressure between the ribs over the heart. The pulse is generally rapid. In pericarditis with effusion, the symptoms usually become worse when the effusion actually appears.

Restlessness and sleeplessness, or mild delirium, with faintness, shortness of breath, an irritating cough and difficulty in swallowing may make their appearance. In children there may be actual bulging of the region over the heart. If pus is present in the fluid the heart rate is very fast, and there is high fever and increasing pallor and collapse.

Treatment.

All cases of pericarditis should be under a doctor's care. The general treatment is the same as for acute simple endocarditis, and of any other disease which may be present. In pericarditis with effusion, removal of the fluid is seldom necessary in rheumatic cases, since it usually becomes absorbed. It is carried out by a doctor by the insertion of a needle attached to a syringe.

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