pneumonia is probably more often caused by weakness of the heart muscle than by embolic processes, so that irregularity of the pulse before the crisis is a bad prognostic sign. On the other hand the murmur of a relative insufficiency is not necessarily serious, when present in a heart otherwise acting with regularity. Sudden death has occurred from cardiac weakness in influenza.

The more remote results of the toxic effects upon the heart in acute infectious, disease, are the production of chronic changes in the different structures, and especially chronic fibroid processes. Regeneration of the muscle cells of the heart takes place to some degree, less, however, than in corresponding tissues in other parts of the body. If the degenerative changes have gone too far, instead of regenerating, the place of the cell is taken by connective tissue, with resulting loss in heart power. The acute myocardial inflammations, with infiltration by round cells near the bloodvessels, and into the interstitial tissues, also increase the fibroid elements in the heart wall and interfere with its activity. The changes in the blood vessels of the heart are particularly serious in their effect. Endarteritis obliterans, occluding the lumen of vessels supplying cardiac muscle, almost surely causes a grave form of acute or chronic degenerative process, and is one of the commonest factors in producing fibrous myocarditis. Thayer" examined 182 patients who had previously passed through an attack of typhoid fever, and a control series of individuals of about the same ages. The typhoid series showed unmistakably a tendency to heart and arterial disease.

In the recognition of the myocardial changes of acute infections, it is important that the systematic examination of the heart be a matter of routine from the beginning. Slight changes in the pulse as well as in the area of deep cardiac dullness give warning of what is to follow, and call for treatment. In acute rheumatism progressive acute dilatation is one of the best signs of acute myocarditis. Poynton says that great enlargement of cardiac dullness which may occur in rheumatic pericarditis is more often the result of

dilatation than of a large effusion. An effusion large enough to oppress the heart in acute rheumatism he considers very It has happened that a paracentesis undertaken to remove the effusion of a pericarditis has ended fatally through puncture of the dilated heart wall.

rare.

In typhoid fever two especial types of heart weakness are encountered; one comes on during the second or third week of the fever, and the other during convalescence. The close observation of patients throughout convalescence and regulation of at least the first weeks of exercise, are necessary if the heart is to be properly guarded. Rapid and irregular heart action, particularly a disturbance out of proportion to the amount of exertion, as pointed out by Babcock, indicate a muscle defect and call for caution.

Treatment of the heart conditions occuring in acute infectious diseases divides itself into three parts: I. Preventive; 2, that of the acute attack; and 3, that of convalescence.

The prevention of heart involvement in infectious diseases is necessarily the treatment of the acute disease itself. In rheumatism the decided impression early by salicylates undoubtedly does much to save the heart from harm. The early use of antitoxin does the same, or more, in diphtheria. Complete rest of body and mind are essential when symptoms of acute heart weakness are observed. The patient should be disturbed as little as possible even for bathing or the giving of medicines. Thompsons advises that the patient. with pneumonia be prescribed periods of absolute quiet of two and three hours.

In the use of drugs for acute heart weakness due to myocarditis or degeneration, there can be no rules of treatment. Digitalis, if used, must be given understandingly, or a threatening dilatation may be hastened when the heart wall is extensively involved. Strychnin hypodermically is of more general application than the other drugs.

During convalescence the avoidance of overstrain of the heart, and the maintenance of the best possible nutrition are most desirable. To this end change of air and scene

are useful. After the acute attack has passed, those who have shown symptoms of myocardial weakness in acute infectious disease should be under observation. If signs of dilatation and weakness of the heart persist, treatment directed toward their relief should be continued. Resistance exercises are of benefit in some instances. Saline and effervescent baths according to the Naunheim method may also be of use to bring about a reduction in the size of the heart and more regular heart action.

I.

Welch-Med. News. April and May, 1888. 2. Cowan-Jour. Path. and Bact., 1903, ix, 87. 3. Paynton-International Clin. 13th, iii, 226. 4. Ziegler-Lehrb. der allg. Path. 1902, II, 30. 5. Jürgensen-Ant. Scar. Fever. Nothnagel's Encyl. 6. Thayer-Am. Jour. Med. Sci. March, 1904.

Babcock-Dis. Heart and Art'l Sys. 1903.

8. Thompson-Jour. Am. Med. Asso. March 19, 1904.

DISCUSSION

Dr. L. W. DaY (Minneapolis): I have in this connection a very interesting case of tubercular pleurisy. The temperature ran high for a week or ten days. When I first saw the patient she had a very large effusion on the left side which I drew off. Almost immediately following the withdrawal, the pulse became very intermittent, and gradually worked up to 140 beats a minute, maintaining its work of an intermittent character. Rest in bed, digitalis, and strychnia were my remedies, but I could see little change. Only two or three days ago I started in with saline baths, and am continuing the treatment. I thought the case might be interesting in connection with this paper.

DR. L. A. NIPPERT (Minneapolis): Since the time of Hippocrates the condition of the heart has been the main criterion of the condition of the patient. To sustain the patient in acute infections means to support the heart until the disease has run its course. The doctor has given us a very excellent paper on the pathological conditions of the heart in acute infections. To know when to stimulate and not overtax the already weakened heart, is one of the chief considerations of successful treatment. As the doctor has mentioned, I think the tendency is to consider that a high temperature is not as fatal to the strength of the heart as it was formerly supposed to be, but that the danger of weakening the heart muscle comes from the toxins carried in the blood-stream. One point was not mentioned by the doctor, and that is the tendency to em

bolisms in acute endocarditis, complicating acute infections. An endocarditis may be so slight in its physical manifestations that it is overlooked until sudden death or multiple infarcts disclose the true pathological conditions. The presence of systolic murmurs over the mitral and pulmonary areas in acute infections is very common, and, barring other signs of valvular disease, they are to be considered as temporary manifestations due to anemia and dilatation. In estimating the strength of the heart, we are guided, first, by the condition of the pulse; second, by the cardiac impulse; third, by the comparative loudness and rhythm of the first and second sound. Of the numerous remedies which will stimulate the heart's action, coffee and camphor have not received as much consideration as they are entitled to in sudden heart failure. If there is the slightest indication of beginning heart failure, absolute rest, on the back if necessary, continued for days or weeks, is of the greatest importance. It has been my unfortunate experience in several cases that neglect of this precaution was followed by sudden death.

DR. SOREN P. REES (Minneapolis): I do not think we pay enough attention to the convalescence of acute cases. When the crisis is past and the temperature goes down in a week or ten days we are inclined to let our patients go, and when they complain of weakness and shortness of breath on slight exertion we tell them that it is natural, and we let them run about and shift for themselves as best they can. The fact is, the heart muscle is so weakened by the illness that, instead of getting strong by running about, they do themselves irreparable injury oftentimes. As good care, with rest, should be insisted upon during convalescence as was given during the acute attack until the heart muscle has become sufficiently nourished and strong, and in that way we avoid a feeble heart later, and perhaps add many years of health to the patient's life.

DR. J. G. CROSS (Essayist): I want to thank the gentlemen for discussing the paper. I have nothing further to add, except to emphasize a few points which perhaps were not sufficiently emphasized in my paper. I purposely left out the discussion of heart failure in diphtheria. I wish to bring out the fact that after infection is past the heart must be observed for a long period. We must watch for the subacute heart changes which lead to chronic heart changes and chronic myocarditis. The symposium of yesterday afternoon showed clearly that the onset is apt to be insidious. The examination of the heart after infectious disease is by no means a useless procedure. The patient ought to understand that there is danger for some time afterward, and especially after undue exercise.

THE RECOGNITION OF TUBERCULOSIS AS A CONTAGIOUS DISEASE

LESTER W. Day, M. D.

Minneapolis

Tuberculosis has been considered in some lands a contagious disease from time immemorial; but in many minds, and even to a surprisingly large extent, to this day has it been looked upon as a matter of heredity. England, in the year 1836, concluded that there was a relationship between cases of tuberculosis and the bad hygienic condition found in the usual home and shop of the worker. She therefore took legal steps providing for more sanitary homes and workshops, and in addition caused to be founded a number of hospitals and dispensaries for the treatment of the tubercular. Partly in consequence of these imperial acts, we may say, the returns of Great Britain show that the mortality from tuberculosis has been diminished from 38 per thousand in 1832 to 14 per thousand of population in 1894.

It was Villemin who first placed the infective nature of tuberculosis on a solid experimental basis. Conheim and Salamonson confirmed his work, but it remained for Koch, in 1882, to isolate the germ, and to prove that it was invariably associated with tuberculosis. And then for the first time, when the cause of the disease and the method whereby it is spread was understood, could intelligent steps be taken toward blotting out the "White Plague." But could anything better illustrate the aversion of mankind toward change than the resistance offered, both within and outside the profession, to preventive measures?

Professor Koch said to Dr. Briggs of New York several years ago: "The adoption in Germany of such measures as are already in force in New York City will not be possible