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7. In very young children diagnosis most difficult.

8. Prognosis better in catarrhal form and worse in virulent
forms of scarlet fever.



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830 REILLY AND SMITH: HEART DISEASE IN INFANXY AND CHILDHOOD.

9. Be suspicious of mastoiditis when there is continuous
fever after free drainage.

10. Remember other serious complications.

1 1 . In treatment of attack proper early measures may abort it.

12. Incision is better than rupture, for it heals better and in
the severe cases should not be delayed until fluid forms. Finally,
appropriate treatment may mean saving the patient's hearing
and possibly the patient's life.

95 Sixth Avekue.



HEART DISEASE IN INFANCY AND CHILDHOOD.*

SOME IMPORTANT POINTS FROM A STUDY OF FIFTY CASES.

BY
D. R. REILLY, M. D.,

and
ARCHIBALD D. SMITH. M. D..

The cases here presented are taken from the Pediatric Depart-
ment of the Bushwick and East Brooklyn Dispensary. Prac-
tically all occurred among the tenement or poorer class, which
does not seek treatment imtil compelled to do so. In fact, the
majority came for some other complaint, and the heart lesion
was discovered in the course of routine physical examination.
Some were referred by the medical inspectors of the public
schools, and would not otherwise have sought treatment.
Even the worst cases, those with broken compensation, were able
to perform their ordinary duties when coming under treatment.
The children were for the most part native bom, though many of
the parents were foreign bom.

Etiology. — In the consideration of the etiology of this group
one is struck with the number of children who have had some
infectious disease. On the other hand, a history of rheumatism
could be obtained in only a very small proportion of cases.
This is in direct contradiction to the statement that rheumatism
is the chief cause of heart disease in children. In making this
division, if there were any evidences of rheumatism whatever,
it was regarded as the etiological factor, so that the benefit of the
doubt goes to rheumatism.

The very general impression that hypertrophied tonsils and

♦ Read before the Section on Pediatrics of the Kings County Medical Society,
February 23, 1910.



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REILLY AND SMITH: HEART DISEASE IN INFANCY AND CHILDHOOD. 831

heart involvement are apt to be associated is not borne out in
this series, as there were only three cases with a history of tonsil-
litis or in which examination showed an abnormal condition
of these glands.

Age. — The age of the patients varied from five and one-half
months to thirteen years.

Frequency. — These fifty cases occurred among 1,500 cases of
all kinds treated between March, 1907, and June, 1909. They
constitute, therefore, 31/3 per cent. These 1,500 cases were
essentially medical, and the figures give a very fair idea of the
frequency of heart involvement.

Heredity. — In only two cases could a history of heart disease
be elicited in the family. In one case the father died of heart
trouble, and in the other the maternal grandmother died of
heart trouble. The latter patient, a girl of eleven years, had
also had chickenpox, measles, scarlet fever, diphtheria, and
chorea.

In only two cases could a history of rheumatism be elicited
in the family. In one case, a child of twelve years, the mother
had had rheumatism, but the child besides having had measles
and whooping-cough, was suffering from rheumatism at the
time of coming under treatment. In the other case, aged
seven and one-half years, the father had had rheumatism, and
the child had had whooping-cough four and one-half years pre-
viously. She came for treatment for bronchitis, and had no
symptoms referable to the heart.

Occupation. — Thirty-nine or 78 per cent, of these cases occurred
in school children.

Race. — ^Forty-seven of our patients were native bom, and
three were foreign bom. In twenty-seven cases both parents
were foreign bom, in nine cases one parent was foreign born,
and in fourteen cases both parents were native bom. The
majority of the foreign bom parents were natives of Russia,
with Austria, Germany, Italy, and Ireland also represented.

Sex. — The sexes are nearly equally represented, twenty-six
females and twenty-four males. These figures are in striking
contrast to those of adult life, where the preponderance is with
the males, and argue for the development of heart lesions after
childhood.

Infectious Diseases. — As mentioned before, the preponderance
of the cases showing a history of one or more of the infectious
diseases is the most striking point in the study of these cases.



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832 REILLY AND SMITH: HEART DISEASE IN INFANCY AND CHILDHOOD.

Forty-two of the cases had had some infectious disease, or 84
per cent. Excluding all other possible causes from this list
of forty-two cases, there are still left twenty-five cases or 50
per cent., in which the infectious diseases were apparently the
only deciding cause. Emphasis is to be laid on this point as it
is in marked disagreement with most of the text-books where
special emphasis is laid on rheumatism. The incidence of the
various diseases was as follows: Measles, twenty-seven; whoop-
ing-cough, thirteen; diphtheria, thirteen; scarlet fever, ten;
pneumonia, eight; chickenpox, seven; mumps and meningitis,
one each. Measles occurred alone as an etiological factor in
seven cases; scarlet fever alone in two; whooping-cough alone in
two; chickenpox alone in two; diphtheria and pneumonia alone
in one each. One case, a girl of thirteen years, had had rheu-
matism twice, chickenpox, diphtheria, mumps, scarlet fever,
measles, whooping-cough, chorea, and had had her tonsils and
adenoids removed.

Rheumatism and Chorea. — Rheumatism was present in the
family history or previous personal history in only eight cases,
and in no case was it the only etiological factor elicited, and
in all but two of these eight cases the patient had suflfered from
two or more of the acute infectious diseases. In these two cases
a previous history of measles was also obtained.

Congenital. — Among these fifty cases there were four of con-
genital heart disease, giving 8 per cent, among the heart cases.
If the percentage of congenital hearts is estimated on the basis
of the whole fifteen hundred cases it gives nearly 0.3 per cent.
The ages varied from five and a half months to nine years, there
being two males and two females. The history given was either
that the baby had been a blue baby at birth, or that the mother
had noticed an abnormal action of the heart since birth.

Idiopathic. — Two cases bore all the ear marks of acquired
heart disease, but nothing could be learned from the history
or from the examination as causative factors, and they are
therefore classed as idiopathic for want of a known etiology.

Clinical Varieties. — Clinically these patients as they come for
treatment can be divided into two separate classes.

1. The patients that come complaining of symptoms referable
to the heart. Eleven cases or 22 per cent, belong in this group.

2. The patients who come with no symptoms referable to the
heart. This class seeks treatment for some other ailment, and
the heart lesion is discovered in the course of a routine examina-



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REILLY AND SBOTH: HEART DISEASE IN INFANCY AND CHILDHOOD. 833

tion. This is the largest group, thirty-nine of our cases, or 78
per cent, falling in it.

Symptoms, — Among the patients who sought treatment for
heart symptoms the most frequent complaint was pain in the
precordial region. This pain was not severe in any of the cases
and amounted in the majority to no more than a feeling of
distress. Palpitation came next in order of frequency, and
dyspnea followed closely. Only one case presented any
edema, that being slight of the feet, and associated with dys-
pnea and a feeling of tmeasiness.

Among the patients who came with no symptoms referable
to the heart the most frequent complaint was bronchitis. Some
were referred by the medical school inspectors of the depart-
ment of health; others came for gastric or intestinal trouble,
tonsillitis and enuresis. The cases referred by the medical
school inspectors came with no complaint whatever.

Physical Signs, — i. Size, Enlargement of the heart was
present in thirty-five cases. The greatest enlargement encount-
ered was in a congenital heart that extended one finger to the
right of the sternum, above to the upper level of the second rib,
and to the left to the mid axillary line, and below to the sixth
rib.

In fourteen cases the heart was not enlarged.

In one case, a mitral regurgitation in a boy of ten years, the
area of cardiac dullness was diminished. There was no associated
emphysema.

2. Impulse. — In the majority of the cases the impulse was in
the fifth interspace. In the cases with marked cardiac enlarge-
ment it was of course displaced outward and sometimes
downward. The area over which the impulse could be seen
and felt was increased in the worst cases, so that it included
nearly the whole of the cardiac area to the left of the sternum.
The greatest displacement of the impulse was to the sixth
interspace in the anterior axillary line in the congenital heart
before mentioned.

3. Sounds. — At the apex the first sound of the heart could be
heard with more or less distinctness in the majority of the cases
in spite of the murmur. In some, and usually in those with the
most marked enlargement, the first sound at the apex was
obscured by the murmur. At the apex the second sound could
always be made out, though sometimes very indistinctly.

At the base the first sound was obscured by the murmur
8



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834 REILLY AND SMITH: HEART DISEASE IN INFANCY AND CHILDHOOD.

in those cases in which it was obscured at the apex. There were
some exceptions to this, however, where the first sound, though
obscured by the murmur at the apex, could be heard more
distinctly at the base. The pulmonary was most frequently
accentuated over the aortic. The second sound at the base was
occasionally obscured by the murmur. Occasionally a redupli-
cated second sound was heard.

4. Thrill. — In nine cases, or 18 per cent., a thrill was felt.
Mitral regurgitation furnished most of the cases in which a
thrill was felt, with mitral stenosis a close second. The thrill
was felt at the apex and corresponded in time of occurrence with
the time of the murmur.

5. Rhythm, — The rhythm of the heart was affected in only
two cases, or 4 per cent. These were both cases of mitral
regurgitation.

6. Murmur. — The quality of the murmur was blowing in the
majority of the cases. The rough, rolling murmur was present
in some. The murmurs were soft and loud, low-pitched and
high-pitched. In the cases where the transmission of the
murmur was at all noticeable, it was not uncommon to hear
the murmur all over the chest in front and behind, and even
to the right scapular region.

The location of the greatest intensity of the murmur depended
on the valve involved.

A functional murmur was present in six cases, and occupied
the usual position over the pulmonary valve. It would not be
out of place at this time to call attention to the fact that the
functional murmur in children is frequently found over the apex.

Distention of the veins of the chest was observed in a few of the
cases. One case in which this symptom was prominent had the
lesion of mitral regurgitation with marked enlargement of the
heart to the right, and was characterized clinically by great
dyspnea.

Deformity of the chest consisting in marked bulging of the
precordial region was present in some of the cases with very
large hearts. In a boy of nine years with a congenital heart
the bony chest wall was displaced outward in totOy forming a
distinct hummock over the greatly enlarged heart.

Pulse. — The pulse was not so much affected as one would
imagine from the damage to the heart in the majority of the
cases. In one case of aortic stenosis the pulse was distinctly
small. In the other cases the pulse was of fair size.



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REILLY AND SMITH: HEART DISEASE IN INFANCY AND CHILDHOOD. 835

The force of the pulse depended on the sounds of the heart.
Where these were good, the pulse was of good force. •

The frequency of the pulse was, as a rule, increased and bore
a direct relation to the severity of the heart lesion.

The rhythm of the pulse was affected as the rhythm of the
heart was affected. This has been mentioned above.

The tension of the pulse was, as a rule, less than normal as
measured by the finger. It was common to find it soft and
easily compressible.

Diagnosis. — The diagnosis in each case was made from the
physical examination, none of the cases coming to autopsy.

The mitral valve was damaged in forty-one cases, or 82 per
cent. Mitral regurgitation alone was present in thirty-six cases,
and mitral stenosis alone in five cases.

The aortic valve was damaged in two cases, one each of
regurgitation and stenosis. Both the aortic and mitral valve
were damaged in two cases.

In one case there was a rapid irregular heart with marked
accentuation of the second pulmonary sound, and a reduplication
of the second sotmd at the base, with symptoms of pain in the
precordial region and headache. No murmur was present
at the first examination. Upon steadying the heart with
digitalis, a murmur of mitral regurgitation appeared.

Congenital Hearts, — The four congenital hearts showed the
greatest degree of cardiac involvement of any of the fifty cases.
The chief complaint in the two older cases, four and one-half
years and nine years, was shortness of breath. In the two
infants, five and one-half and seven months, the mothers^stated
that the "heart was beating too fast." In one of these latter
the pulse rate was 160 per minute.

These four hearts were markedly enlarged in every direction.
The dimensions of the largest have been described above.

While the diagnosis of the lesions in congenital heart disease
is proverbially diflScult, some facts could be established. These
facts were the involvement of the pulmonary, aortic, and mitral
valves. The involvement of the tricuspid was suspected in
one case. Beyond that point the lesions were a matter of con-
jecture. Whether we were dealing with a patent foramen ovale,
a deficient interventricular septum, a patent ductus arteriosus,
or a combination of one or more of these lesions could not be
definitely determined.

Prognosis. — The outcome of all of the cases could not be



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836 &EILLY AND SMIXH: HEART DISEASE IN INFANCY AND CHILDHOOD.

learned, this being one of the disadvantages associated with
dispensary patients. Where we were able to follow the course
of the disease under treatment, even the worst cases were
discharged free from symptoms. Although the damage to the
heart could not be repaired, compensation was restored. Even
the congenital cases were comfortable while imder treatment,
but if this were omitted for a period of time they would return
with the same old complaints.

Treatment. — Rest in bed is the most important part of the
treatment in restoring the broken compensation of one of these
hearts. It should be absolute and uninterrupted, and in some
cases continued for a long period of time, weeks and even
months.

In many of the cases limitation of the daily activities will
suffice.

General tonics, as iron, arsenic, and strychnine did good
service in some of the cases.

Digitalis was used with satisfactory results in some cases, but
the sheet anchor where heart stimulation was required was
tincture of strophanthus, in 2 to lo minim doses pro re naia.
The larger dose was given once only when indicated, and
followed by a smaller dose.

Where there was evidence that rheumatism was active the
salicylates were used.

Strophanthus is better borne by the stomach in children than
digitalis, and it has no cumulative effect. Its action is more
prompt than digitalis. It slows an overacting heart, prolonging
the period of rest. It increases the force of the individual heart
beat, and increases the blood pressure by its action from behind,
but does not contract the peripheral vessels as digitalis does.

From our experience we are convinced that it is, when indi-
cated, a better drug in children than digitalis.

Conclusion. — Attention is especially directed to the following
facts:

1. The surprisingly large number of heart lesions among
children who have suffered from the infectious diseases. This
would argue for the more careful supervision of such patients
and is an especially strong argument against the home treat-
ment by parents and other unqualified persons of the acute
infectious diseases, especially measles.

2. The large percentage of children suffering from heart
disease who present no symptoms (subjective.)



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HAMILTON: TREATMENT OF GONOCOCCUS VtJLVO-VAGINITIS. 837

3. The value of routine examination of the chests of all
children regardless of their complaint.

4. The favorable prognosis.

The last three are correlated. In view of the favorable prog-
nosis of heart disease in children tmder treatment, and the large
number of children suffering from heart disease but who present
no subjective symptoms, it would seem that the careful routine
examination of the heart of every child coming under the obser-
vation of the physician were an imperative duty, especially since
we are aware of the prevalence of long-standing heart trouble in
adults and the misery it entails.

97 Halsey Street.



VACCINE TREATMENT OF GONOCOCCUS VULVO-
VAGINITIS IN OUT-PATIENT CHILDREN.

BY
B. WALLACE HAMILTON, M. D.,

Physician to Children's Clinic, Presbyterian Hospital' Dispensary. Clinical Assistant,
Department of Pediatrics, Vanderbilt Clinic,

New York City.

Great difficulty in getting any permanent results in out-
patients by the ordinary methods of irrigations and instillations
of astringents in the treatment of gonococcus vulvo-vaginitis
led to the experimental use of antigonococcus vaccine. Con-
sidering the bad hygiene and local tmcleanliness of these cases,
the results have been most encouraging, reducing the length
of time spent in treating them with local remedies to a marked
degree. Microscopical examination of smears from the vaginal
secretion all decolorized by Gram's method. All others or
doubtful cases are excluded from this report. The doubtful
or "suspicious" cases showing many leukocytes in the stained
smears of the secretions, are not here considered.

Age, — Of the total cases observed the average age was five
and one- tenth years; the youngest aged three weeks, the oldest
being twelve and a half years.

Following the results of Cole and Meakins* in the use of
vaccine therapy in gonorrheal arthritis in adults, the record of
twenty-five cases reported by Butler and Longf and forty-one

♦ Treatment of Gonorrheal Arthritis, by Rufus I. Cole and J. C. Meakins.
Johns Hopkins Hospital Bulletin, Tune- July, 1907.

t Vaccine Treatment of Gonorrheal Vulvo-vaginitis in Children, by W. J. Butler
and J. P. Long. Jour, A, M, A,, March 7, 1908.



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838 HAMILTON: TREATMENT OF GONOCOCCUS VULVO- VAGINITIS.

cases reported by Churchill and Soper,* the two latter in
children confined in hospitals, the same treatment was under-
taken in out-patient cases. Eighty-four cases in all have been
treated by this method. Owing to the cases being out-patients,
and to the lack of time and observing the experience in the
use of the vaccine in adults, I omitted taking the opsonic indices,
except in a few of my early cases, as I do not deem it necessary,
since there does not seem to be any relation of the index to the
vaginal discharge. Three separate vaccines were used: i.
Vaccine prepared from a sixteen- to eighteen-hour blood-agar
culture from male uretheritis, prepared after the method
devised by Dr. R. V. Lamar, of the Rockefeller Institute for
Medical Research. The strength of the emulsion was loo
million bacteria to one cubic centimeter. 2. Vaccine from a
stock culture at the Presbyterian Hospital belonging to Dr.
J. C. Meakins. The strength of this emulsion was also 100
million to one cubic centimeter. 3. Stock vaccines prepared
by Parke, Davis & Co., the strengths of which were 100 million
and 500 million per cubic centimeter. No attempt was made to
use the autogenous or personal vaccine made from the patient's
own organism.

The injections were made with an ordinary glass hypodermic
syringe into the gluteal muscles under strict asepsis. In using
small quantities of the vaccines sterile physiological salt solution
was used as a diluent.

The number of vaccinations in the individual cases varied
according to the age, severity, and chronicity, the smallest
number to accomplish a cure being four, and the greatest number
being eighteen.

Dosage, — In endeavoring to arrive at some conclusion regarding
the dose of vaccine to administer to children, I took one of the
older children affected for a long period, whose parents were
above the ordinary out-patient in intelligence. This child
was eight years of age and had been treated by the irrigation
treatment for seven months. The child was put to bed under
the constant care of a nurse and 1000 million killed bacteria
were injected into her buttock at one dose each day for three
days. Her temperature, pulse, and respiration were taken
every two hours. She not only showed no rise of temperature,
but no local reaction whatever and no subjective symptoms.

♦ Inoculation Treatment of Gonorrheal Vulvo-vaginitis in Children, by F. S.
Churchill and A. C. Soper. Jour, A. M. A., October 17, 1908.



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HAMILTON: TREATBfENT OF GONOCOCCUS VULVO-VAGINITIS. 839

In the majority of cases, regardless of age (except under six
months), I started the treatment by an injection of 50 million
every fifth day, increasing the dose 10 million until five injec-
tions were given, i.e., 90 million. The intervals were now
made seven and ten days before another was given, smears of
the remaining secretions being taken and examined by Gram's
method each visit after the fifth injection. In most of the
acute cases six injections were sufficient for a complete cure.
In the cases of long standing it was necessary to use an increased
number of injections, bringing the doses up to 200 million. No
case was pronounced cured except those free from gonococci by
Gram's method, once weekly for four weeks and after two
additional examinations at intervals of two weeks. If no organ-
isms were present after these six examinations and no discharge
was present, I considered the child cured. I have had nineteen
children return to the clinic after a period of three months
following the final examination and found no evidences of the
infection present.

In a very few cases an extremely slight local reaction took
place at the site of the injection, but this in every case subsided
in twenty-four hours. The reaction was never suflBcient to
cause any pain or tenderness. General constitutional disturbance
never occurred after any of the injections. Temperature charts
were kept of cases, the temperature being taken twice daily by
the visiting nurses who visited the patient's home each day
while under active treatment. No distinct rise in temperature
following an injection was noted in any of the cases. No local
treatment whatever was used in any of the cases, except external
bathing where excessive secretion was present. No irrigations
were given. Of the eighty-four cases treated by vaccines^
sixteen were cases of long standing which had been treated by
other metliods, in the majority of cases permanganate irrigations,
were previously used. Gonococci were present in all before in-
stituting the vaccine treatment. These latter cases required a
larger number of vaccinations and an increased dosage.

In order to appreciate the value of this newer form of vaccine
treatment in out-patients it would be fitting to note the intract-
ability of this disease when local means of treatment were used.
For the past three years I have kept an accurate record of all
cases at the Vanderbilt Clinic of proven vulvo-vaginitis of
gonococcus origin and have made a comparative table of the
results as follows:



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840 HAMILTON: TREATMENT OF GONOCOCCTJS VULVO- VAGINITIS.



Total
Treatment no. cases

1


Cured

158
76


Uncured


Lost


Per
cent.


Irrigation



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 86 of 109)