THE Medical Bulletin. JOHN V. SHOEMAKER, A.M., M.D., Editor. THE F. A. DAVIS CO., Publishers. 8. C. BERGER, Business Manager. Philadelphia, April, 1894. CARDIAC DISEASE IN ERYSIPELAS. tion between facial erysipelas and disease of the heart appears in a recent number of a French exchange.* The writer, Dr. L. Galliard, reviews the subject in connection with the histories of 350 cases of facial erysipelas under his care during the years 1891 and 1892. Gubler was the first to report, in 1864, the development of a cardiac murmur in the course of an erysipelas. In the following year Durozier noted, at an autopsy, injection and thickening of the pericardium of a patient who died of the same infection. Shortly afterward the attention of Professor Jaccoud was drawn to T is always of interest to study the rarer the subject, and he promulgated his belief that infectious diseases. The recognition of such accidents broadens our clinical pictures. It prevents our being surprised at the advent of unusual phenomena. It enables us to promptly take such measures as are adapted to the relief of the additional difficulty. The effect of febrile process upon the structure and action of the heart has long been studied. The specific influence of certain diseases, notably acute rheumatism, in producing inflammatory changes in that organ, is a fact that is daily demonstrated. To the patient who suffers from rheumatism the pain in the joints is the most important feature of The attending physician anxiously scrutinizes the condition of the heart. Erysipelas, a frankly infectious malady, is interesting from many points of view. In former years the operator dreaded it as a frequent complication of accidental or surgical wounds. Much discussion was held as regards its pathogenesis. The identification of the micro-organism by which it is excited, and the general adoption of antiseptic methods, at once placed our knowledge on a firmer basis, and rendered the appearance of erysipelas in the surgical wards an unusual mischance. Erysipelatous lesions of mucous and serous membrances, of the joints, of veins and lymphatic vessels, are well known occurrences. That the disease enfeebles the heart is a fact universally admitted, but it was not until recent years that erysipelas began to be regarded as the possible cause of cardiac lesions. An interesting communication upon the rela dry pericarditis, is by no means an exceptional result of erysipelas. M. Galliard, on the other hand, records his experience that such a complication must be regarded as a rare event. Among his 350 cases he found only six in which a cardiac complication could be properly looked upon as due to the disease. In only one case out of twelve did the development of erysipelas seem to aggravate the symptoms due to pre-existing cardiac disorder. In the autopsies M. Galliard never found cardiac lesions which were not associated with cardiac atheroma or cardiac nephritis. Jaccoud thus sums up the points which enable us to distinguish an erysipelatous endocarditis: "I attribute to a recent endocarditis the murmur only which corresponds to the following conditions: it is systolic at the apex; it originates in the course of, or some hours before, an erysipelas; it is independent of the degree of fever, which it may outlast; it occurs in a patient who has never been affected with articular rheumatism or pleuropulmonary inflammation; it supervenes during an erysipelas which is not actually complicated with pleurisy or pneumonia." The only case in his series which M. Galliard felt justified in regarding as erysipelatous endocarditis concerned a young man who, until the seventh day, presented a systolic murmur extremely intense at the apex. After the ninth day the sound grew less distinct, and eight days subsequently, when the patient quitted "L'Erysipèle de la Face et le Cœur." Par L. Galliard, in La Médecine Moderne, Feb. 10, 1894. the hospital, scarcely any anomaly could be light that it could with difficulty be recogdetected upon auscultation. nized. Neither is pericarditis common as a consequence of erysipelatous nephritis in the cases examined by the writer from whom we quote. He adduces several instances in which the pericardial complication was absent in well-marked cases of acute nephritis dependent upon erysipelas. He, therefore, insists upon the importance, in every case of pericarditis occurring during the course of an erysipelas, of examin Achalme declares that erysipelatous endocarditis is usually cured without leaving any consequences, but that, in rare instances, it may lead to the development of the chronic form. He adds that it is, therefore, analogous to the rheumatic lesion, especially as it may coincide with the presence of articular complications. M. Galliard, however, regards the occurrence of pseudo-rheumatism in facial erysipelas as even more exceptional than endo-ing the urine carefully, as the kidneys are very carditis. Even in undoubted rheumatic subjects he has never seen erysipelas awaken the latent diathesis. Phlegmonous erysipelas of the limbs, indeed, may be complicated by suppurative arthritis. The writer cites a case which he had reported in which suppuration of the knee took place on the sixth day of a facial erysipelas and caused death. At the post-mortem examination nothing was found but nephritis. There was no endo-pericarditis or apparent lesion of the myocardium. Erysipelatous pericarditis, existing alone or accompanied by endocarditis, may occur in two forms. One is mild, transitory, and curable, and does not give rise to effusion. The second variety is grave, associated with pleurisy, pneumonia, nephritis, or multiple suppurations, and marked by serous or purulent effusions. According to Spillmann, pericarditis is less frequent in erysipelas than endocarditis. M. Galliard believes that both complications are exceptional, and that it will usually be found that the cardiac lesion depends either upon an old rheumatism or upon a nephritis, which may be caused by the erysipelas or may have pre-existed. In support of his opinion he cites the case of a man, alcoholic and syphilitic, attacked by facial erysipelas. He was delirious, and the urine contained albumen from an early period. About a month after the beginning of the illness there was hydrothorax of the left side, and pericardial friction-sounds were perceived. A few days. later a second attack of erysipelas supervened. Nevertheless, when the patient was discharged, about six weeks from the first manifestation of erysipelas, but a trace of albumen was to be found, and the friction-sound had become so sensitive to the action of the streptococci. In conclusion, he declares that upon a vigorous investigation and rejecting doubtful cases he found, in the series of three hundred and fifty, only two undoubted cases of pericarditis as a direct consequence of facial erysipelas. One of these was severe. On the fourth day a decided pericardial friction-sound was heard. This sign was, on the seventh day, replaced by a systolic murmur and, at the same time, cardiac dullness was slightly increased. Upon subsequent days the friction-sound re-appeared, the action of the heart became very irregular, rapid, and also feeble. Disseminated bronchial râles were present upon the eighteenth day. By the twenty-seventh day the erysipelas had disappeared, and the friction-sounds could scarcely be detected. For several days thereafter the pulse-rate was extremely variable, and upon the forty-first day the patient was dismissed. The preceding case could justly be looked upon as one of erysipelatous pericarditis independent of rheumatism, nephritis, or any secondary influence. The endocardium seemed to escape, but the arhythmia, the pain, and the rapid and intermittent pulse pointed to alteration of the myocardium. Pyo-pericardium has occasionally been found co-existing with multiple suppurations. In fatal cases pericarditis was generally accompanied by endocarditis and pleurisy. Lesions of the muscular substance of the heart are still rarer than endo-pericarditis in pleurisy. M. Galliard found but one casesketched above-in which the signs pointed to involvement of the myocardium. The result of the autopsies corroborated the judgment formed at the bedside. To naked-eye inspection the substance of the heart generally appeared healthy. they had command of military hospitals for the care of contagious diseases. These men were in command or in charge of hospital trains, hospital boats, ambulance trains, and were executive officers of United States general hos In the large number of cases-sixteen hundred and seventy-four-recently studied by Prof. James M. Anders, of this city, endocar-pitals. They acted as brigade and regimental ditis occurred but in one instance, the case being of the ulcerative variety. In not a single case was erysipelas complicated by pericarditis. surgeons, and at least one acting assistant surgeon occupied the position of medical director of a department for nearly a year. The acting assistants were responsible for hospital funds and property, served on courts-martial, on ACTING ASSISTANT SURGEONS OF boards of survey, in camp, field, and garrison. THE UNITED STATES ARMY. URING the civil war, in order to meet Since the civil war they have served on overland expeditions and in Indian wars. It is service, 150 died in the military the government adopted the plan of employing service of the United States. They were physicians from civil life to perform the duties allowed the same fuel, rations, quarters, transof military surgeons. This method of employ-portation, and traveling expenses as commisment by contract, as it was termed, was not sioned assistant surgeons. When disabled by altogether a new one at the time, but had pre- reason of disease contracted or injury received viously been resorted to under special circum- in the military service, they have been granted stances before the outbreak of the war between pensions under a law which assimilates them to the States. It has also been continued since the rank of first lieutenant in the military or that period. As a matter of course, however, marine corps. the great majority of men who have lent their services to the government in this position performed their duties during the great war. Large armies had to be hurriedly raised and organized. The pre-existing machinery of the army was totally inadequate to fulfill the calls made upon it, and as the little regular army was rapidly expanded into a great volunteer host, so the medical department was obliged to seek assistance from civil life. The number of the commissioned medical staff was far from sufficient for the necessities of the service. These men responded to their country's call just as devotedly as any private or commisioned officer of the combatant force. They willingly offered themselves in the time of a great national emergency. The contract under which they served was as sacred to them as a commission. Called from civil life at a critical period, they resumed the peaceful pursuit of their calling when the unhappy strife was ended. It is certainly a singular fact that a body of professional men, who have served in camp, field, hospital, or the frontier, amid the scenes of civilized or savage warfare, should find themselves under any disability in comparison with others who, under precisely the same circumstances, performed precisely the same duties. Yet to such unjust discrimination have acting assistant surgeons long been subject. With the same patriotic recollections as other enlisted or commissioned men who served their country during the civil war, they are, by a paltry technicality, excluded from membership in organizations such as the Loyal Legion and Grand Army of the Re Men thus employed were known officially as acting assistant surgeons. It was stipulated in the contract that they should remain in the service of the United States for a certain time. It goes without saying that during that time they performed exactly the same duties and were exposed to precisely the same hardships and dangers as officers actually holding the commission of assistant surgeon. The acting assistant surgeons executed their duties with faithfulness and ability equal to those displayed by commissioned officers of the same grade. They were on duty in the field; they had charge of post, field, division, and general hospitals; | public. These gentlemen have long been dissatisfied with the anomalous position they occupy in comparison with others whose services, whose hardships, whose dangers, were no greater than their own. They have banded themselves together in an "Association of Acting Assistant Surgeons," and are endeavoring to have their disabilities removed. In their behalf bills have been, during the present session, introduced into the Senate and House of Representatives, setting forth the grievances of which they complain. Their movement should command the sympathy and co operation of every member of the medical profession. We would suggest that every reader of these lines make use of all the influence he can command in favor of so worthy a cause. Those who have themselves occupied the position of acting assistant surgeon will feel themselves especially called upon to use every means within their power to further the movement. THE USE OF DIGITALIS IN THE DISEASES OF CHILDREN. M.J. J. COMBY, physician to the hospital Tenon, of Paris, and a well-known writer opon the maladies of childhood, devotes a recent article to a review of the therapeutical applications of digitalis in young subjects.* He finds that though children are very sensitive to its action, as to that of all powerful remedies, especially those which have an influence upon the nervous system, they support its various preparations well in proper doses. In cardiac affections asystole furnishes the principal indication for the use of digitalis. This drug is a tonic to the heart. It is, as has been aptly said, the quinine of that organ. It is beneficial in congenital maladies, with or without cyanosis, by strengthening the cardiac contractions, which are almost always insufficient, and by promoting diuresis. It is capable of rendering service in both endo- and pericarditis, whether of rheumatic origin or dependent upon some M. Comby does not, however, regard the drug as serviceable in the case of infants or young children attacked by nervous palpitations. other cause. * "La Digitale chez las Enfants." Par J. Comby, in La Médecine Moderne, Feb. 17, 1894. In diseases of the respiratory apparatus it is useful in pleurisy and hydrothorax, in which, by its diuretic action, it favors absorption. In pneumonia, when the heart is feeble and the fever high, digitalis may be employed with good effect. Its administration is advised in bronchitis attended by fever, in epidemic influenza, and in broncho-pneumonia. In hæmoptysis, which is abundant or disquieting by reason of its repetition, digitalis is serviceable, not because it has any influence upon the primary cause of the hæmorrhage, viz., tubercle, but by reducing the pulmonary congestion in accordance with the retardation of the action of the heart. In acute attacks of renal disease accompanied by fever, abundant albuminuria, scanty and high colored urine, M. Comby does not advise the employment of digitalis. In chronic affections, however, such as nephritis or passive congestion, with or without anasarca, digitalis may render an excellent service. The same remedy is of value in the treatment of acute infectious diseases, as diphtheria, typhoid fever, scarlatina, etc., if employed in time, before serious degeneration of the heart has occurred. It has been asserted that digitalis is a sedative to the nervous system, and, with this view, it has been administered by Duclos in epilepsy. Isambert, in the case of a maniacal child, 14 years of age, saw the delirium yield to the administration of 30 drops of the tincture of digitalis. The direct sedative action of the drug is, however, by no means assured. Digitalis has been employed in a host of maladies, of which it is unnecessary to make mention. Dr. Pilatte, of Nice, praises its action, when used internally and externally, in chilblains. M. Comby deprecates the administration of He recrystallized digitaline to children. gards this alkaloid, which, moreover, represents but a part of the action of digitalis, as dangerous in patients of tender years. The same statement is made as regards amorphous digitaline. The author prefers to make use of the extract, tincture or syrup. If the child is old enough a pill may be given, made of the powdered leaf. The infusion is an excellent mode of administration. The syrup is an agreeable preparation for children. It is made from the tincture in such a manner that 5 fluidrachms of syrup contains 15 drops of the tincture. "BASE INGRATITUDE.” SUITS should be above the sordid acquisition of wealth. His motive for the pursuit of his chosen profession must come from his heart; but when one meets with such "base ingratitude" as these nine physicians are receiving at the hands of unmitigated scoundrels or blackmailers, it is enough to chill the softer feelings within themselves and make Shylocks of them all. With all due respect to those Nestors in the profession who constantly preach that the practice of medicine must be conducted on humane lines, and not by business methods, we say, that the students of medicine and the younger practitioners must realize and accept the fact that that day is passing away. When business methods prevail, then we shall not have suits of malpractice hanging over us to annoy, con UITS for malpractic against physicians have grown to an alarming extent in the last few years in this city. We understand that nine suits are now entered on the dockets of the various courts, and the damages claimed vary from ten to seventy thousand dollars in each individual case. One suit which was recently disposed of is about the history of all of them. After the physician had done all in his power to alleviate a blind man (charity patient), he was rewarded for his pains by hav-sume our time, and abstract tribute for defense; ing a suit for malpractice instituted against him for twenty-five thousand dollars' damage. The suit was that of H. L. Hershey against Dr. L. Webster Fox. The action was brought to recover damages for the loss of an eye after a needle-operation for secondary cataract. In 1883 Dr. Fox removed a cataract from the left eye of this patient; two years subsequently a needle-operation was performed, and vision restored. In 1888 a cataract was removed from the right eye successfully; two years later this was followed by a needle-operation on the capsule, which obscured the vision in this eye; ten days after the operation inflammation developed, and the eye was lost. There were several important points brought out in the trial which are well worth preserv-. ing in the minds of all surgeons :— First. It remains with the plaintiff to prove that carelessness and want of skill and due diligence were manifested on the part of the attending physician. It is not absolutely necessary for the physician to inform or explain to the patient the character of the operation to be performed. Third. That the physician is not responsible for the results of an operation, so long as he uses a reasonable amount of skill and care. The medical profession requires the highest skill, constant study, and unselfish devotion to the interests of mankind, and the medical man for such suits only come from those for whom we have given time, mental anxiety, even money out of pocket; our compensation—nothing. The unprecedented remarks made by one of our most honored judges, in granting a nonsuit in Dr. Fox's case, are well worthy of being repeated, and we are sure that they will have a wholesome effect upon a class of people who, unfortunately, will always be amongst us,ingrates. Judge Biddle said: "I do not see the slightest evidence in this case of any malpractice whatever. This man was attended for eight years, and a most serious operation performed upon him (and he paid the doctor ten dollars, which was paid the optician for glasses), in addition to attending his wife and giving him prescriptions for other matters. I think it is a case of base ingratitude for the services that were rendered. I grant a nonsuit." Philadelphia is justly proud of her judiciary, and the medical fraternity throughout this broad land should thank Judge Biddle for so thoroughly scoring such an ingrate. Dr. Fox has done the profession a good turn by his determination in fighting this suit to its end. DR. LONGBILL: "Is the boy costive?" Father of Sick Boy: "Costive? Vell, I should say! Dat poy has cost me over ein hundred dollars already!" |