disease. 5. Inocculation has no effect on other diseases, except, possibly, eczema, which appears to be benefited. 5. Inocculation confers a high degree of immunity and greatly reduces the number of plague attacks. 6. When, in spite of innoculation, a person takes plague chances of recovery are increased, and still the death rate is close to fifty per cent.

Preliminary Report on the Treatment of Advanced Pulmonary Tuberculosis by Intravenous Injections of Iodoform.-In the British Medical Journal for Nov. 21, T. D. Dewar presents the above report. He uses iodoform dissolved in ether, one part to seven, beginning with a daily injection of from five to seven minims, and gradually increasing the amount. He has given as much as forty-five minims at a dose in cases not too far advanced. The solution should be made fresh at each injection. It is given slowly in as large a vein as possible. The successful injection is painless. If pain occurs the pain should stop. In all of his cases both lungs were affected. Elastic tissue and tubercle bacilli were found in the Sputum. In every instance improvement was great and rapid. Physical signs improved, temperatures became normal, weight and vigor increased. The expectoration and bacilli diminished.

Typhoid Fever.-Dr. Seymour Taylor, of the West London Hospital, has some very interesting points on typhoid fever in the Lancet. In his experience diarrheal diseases predispose to typhoid. He mentions three young men on vacation. Two had slight diarrhea, the third none. All three were exposed to typhoid by drinking contaminated water. The two with the diarrhea developed severe typhoid, the third escaped. Incubation in both cases was ten days. Relapses, Taylor believes to be due to change in treatment. In thirty-five per cent. of his cases relapse followed change of diet; in 23 per cent. relapse followed enema or cathartic. The author enumerates three dangerous symptoms in typhoid; namely, tremor, delirium and a persistently high evening temperature104 to 105 or higher. An abrupt fall of temperature means usually perforation or hemorrhage though diarrhea may cause it. Sudden fall of temperature, with sudden fall in pulse, diminished tension and dicrotism, followed by fever probably means perforation, and the surgeon should be called. Five days of continued remittent should cause suspicion of typhoid.

NORTH AMERICAN

JOURNAL OF HOMEOPATHY

Original Articles in Medicine.

SOME OBSERVATIONS CONCERNING THE DIAGNOSIS

OF HEART DISEASE IN INFANCY AND

CHILDHOOD.*

BY EDWARD R. SNADER, M. D.

Philadelphia.

THE HE diagnosis of any form of acute heart disease in infancy and childhood is notably difficult, and I may say with reason, sometimes impossible-impossible if it be necessary to reach. an immediate positive conclusion as to the exact nature of a suspected lesion.

The congenital lesions can seldom be diagnosed as to their particular departure from the anatomical norm. We can know that there is a defect in the action of the cardiac pump, but we cannot always be certain as to what valve or what opening is affected, or whether this or that septum is absent or perforated, or whether the vessels are transposed, or whether the foramen ovale is patent or not. The most constant sign of congenital heart disease is a systolic murmur heard over the pulmonary area or the left body of the heart. This sort of murmur is heard with all kinds of heart defects of the congenital anatomical type. While, with an elaborate study and abundant opportunity for frequent observation, we may occasionally decide that the systolic murmur discovered soon after birth (without the subsequent intervention

* Read before the Penn. Homeo. Med. Society

of any disease capable of causing a heart malady after birth), has a particular significance and represents a particular lesion, in the vast majority of instances this diagnostic result is not possible; and we are compelled to content ourselves with the diagnosis of "Congenital Heart Disease," and to leave its special form a matter of surmise and conjecture.

Perhaps the most frequent lesion represented by this systolic murmur of congenital heart disease is an unclosed or partially closed foramen ovale. I am satisfied, however, that partially closed foramen ovale exists at times without murmur, and hence there is no reason to suspect its existence. Cyanosis, the symptom above all others most constantly associated with congenital cardiac maladies, is not by any manner of means always pronounced, and may, indeed, be entirely absent, in not only patent foramen ovale, but also in other less obvious anatomical defects in the heart structures. I am led to take this view concerning the absence of murmur in some of these cases because of the observation frequently made by Professor Rufus B. Weaver, that his discovery of a partially closed foramen ovale in his adult dissections is so frequent as to be common, and while he does not go into figures as to the ratio of patent to unpatent foramen ovale in adults, the fact of their frequent presence and clinical innocuousness is only too obvious. It cannot, of course, be proved that these cases did not have auscultable murmurs sufficiently obvious to a careful observer to have led to a suspicion of a cardiac disorder. Unfortunately a clinical history does not accompany dissecting material as furnished by our Anatomical Board; but, nevertheless, it seems to me a fair assumption that, in the numerous instances of partially closed foramen ovale discovered in the dissected adult heart, a fair proportion was not represented during life by a discoverable systolic murmur in the usual or any other situation. Clinically we need not worry ourselves about these undiscovered cases of unclosed foramen ovale, for, as a rule, when they do not produce a murmur they do not produce important symptoms and when sufficiently grave to induce severe clinical phenomena, in themselves are the measure of the gravity of the case, even in the absence of murmur, whether congenital or acquired, and also furnish the necessary indications for treatment.

In the acquired forms of heart disease the inferential diagnosis is sometimes extremely easy and sometimes extremely difficult. The valvular diseases are far more frequent in infancy and childhood than is even dreamed of by the hurrying physician. Eighteen-twentieths of the cases are never recognized at the time.

of their inception or during their progress. This fact is shown by the discovery, in countless instances, in adolescence or adult life of murmurs representing grave valvular lesions without any clinical history whatever to suggest that the lesions had been discovered when they were in progress acutely or subacutely. These lesions of the endocardium will continue undiscovered if the profession does not awaken to the fact that endocarditis accompanies other diseases besides inflammatory rheumatism and scarlatina. The conception must be had that all the exanthems, all the pneumonias, all the diseases causing alterations in the character of the blood, from so-called lithiasis to biliousness, can cause endocarditis. If I were to trust my own experience I should emphatically say that endocarditis more frequently accompanies tonsilitis than any other malady. You can call tonsilitis rheumatic if you will; I care less now for the pathological condition than for the general recognition of the clinical associations of endocardial inflammations. A conception of the clinical associations of endocarditis is essential, in order that the inflammatory process be diagnosed at a time when the secondary changes in the lining of the heart may at least be limited and mitigated, if not subsequently cured. It is most necessary that the possibility of the occurrence of endocarditis more readily in the young than in the adult be apprehended, and also that endocarditis may run its entire course in connection with some other disease of which it is a complication or sequence, without the presence of a single definite, positive symptom pointing to the heart as the seat of primary or secondary manifestation of disIn the absence of symptoms, in a failure to recognize the widespread clinical relationship of endocardial inflammation to the most diverse and opposite disease pictures, and, most of all, to a failure to examine the heart properly (and make use of the methods of physical diagnosis), is due the reprehensible fact of the too frequent non-recognition of inflammation of the endocardium in infancy and early childhood.

ease.

I may say, in passing, that this lack of discovery of lesions of the endo- and pericardium is just as true in adults as it is in children. While exceptionally the diagnosis of endocarditis may be difficult it is usually possible if a suspicion of a presence of the malady be entertained and careful and repeated examinations made. I am almost inclined to believe that the general practitioner will be more likely to discover that relatively rare lesion, ulcerative endocarditis than the simpler and more frequent form of involvement of the heart's lining, because in some of these

malignant cases the clinical phenomena may point indubitably to the heart, at some stage of the disease, as a causative factor for the presence of certain symptoms.

The myocardites, and the cardiac dilatations of infancy and childhood are, in some instances, specially difficult to discover because of certain peculiarities in the normal signs of the young heart. The sounds of respiration in the young are sometimes so loud and so harsh as to obscure the presence of a murmur and make difficult of detection modifications that take place in the character of the heart sounds as the result, not only of endo- and pericarditis, but of myocarditis and dilatation. Aside from this loud respiratory sound the restlessness of the patient during a prolonged examination is not an unimportant factor in the difficulties attending the investigation and diagnosis of cardiac disease in children. The superficial cardiac space, too, is higher and relatively much smaller than in the adult. The position of the apex beat is further removed from the centre of the sternum, is higher in situation, and more movable than in the adolescent and adult heart. Up until the sixth year, at least, and sometimes still longer, the pulmonary sound is accentuated normally in the young, and thus alterations in the character of this pulmonic second sound so invaluable in the diagnosis of left-sided chronic valvular affections of the heart in the adult, is either of no value, or must be discounted, or most carefully weighed before being accepted as evidence of cardiac disease when it is found in the very young.

Despite all these disadvantages, however, the diagnosis of endocarditis in infancy and childhood is sometimes made with the greatest ease and certainty, while in others it remains a suspicion only, to be made positive or negatived, perhaps, long after convalescence has been established. I recall several cases in which I suspected the presence of endocarditis, but the evidence present seemed to me at the time insufficient upon which to base more than a tentative diagnosis, in which several months afterward I detected a well-marked and unmistakable murmur, with all the accessory evidences of valvular involvement.

Given a case of any sort of illness capable of producing serious blood changes in which I can discover a murmur that grows in intensity day after day, and I am willing to diagnose endocarditis. I do not expect at this stage to find enlargement of the heart or material alterations in the character of the heart sounds (save the muffling caused by the beginning of the murmur or its actual presence). Those modifications occur later, often when the patient is