ARTICLE L.

HEART COMPLICATIONS IN

DIPHTHERIA.

A CLINICAL STUDY OF 946 CASES.

BY FRANKLIN W. WHITE, M.D.

AND

HOWARD H. SMITH, M.D.

OF BOSTON.

READ JUNE 7, 1904.

HEART COMPLICATIONS IN DIPHTHERIA; A CLINICAL STUDY OF 946 CASES.

THIS paper consists of a clinical study of nearly one thousand cases of diphtheria treated at the Boston City Hospital, South Department, during one year. We have studied mainly the condition of the heart to determine the character and frequency of heart lesions and their practical importance in prognosis and treatment. We shall present some general statistics of all the cases, taking up certain cardiac signs and symptoms which were common to large numbers of the patients, and also a special consideration of a small group of cases in which the heart symptoms were especially prominent and important.

Age. The patients, naturally, were mostly children. Their ages were as follows:

About 5 per cent. were less than one year, nearly 40 per cent. less than five years, and about 70 per cent. less than ten years old.

Sex.-The sexes were almost equally represented.

Severity. In about one-quarter of the cases the course was mild, about one-half were moderately ill, and in onequarter the illness was severe. Over one-half of the severe cases proved fatal, namely 132. This classification is based on the amount of toxæmia, the amount of membrane, and the presence of complications. The following table gives the number and per cent. of deaths at different ages:

WHOLE NO. OF CASES. NO, OF DEATHS. PER CENT, OF DEATHS,

About one-half of the patients died of broncho-pneumonia, usually following operative interference such as intubation or tracheotomy. About one-fourth died of heart complications. Of the remaining one-quarter, the majority died of early severe toxæmia, and a few of asphyxia, or late paralyses.

About 50 per cent. of the patients were discharged from the hospital within four weeks, about 40 per cent. between the fourth and seventh week, only 10 per cent. remained longer than seven weeks. The length of the stay in the hospital was governed by the presence of diphtheria bacilli in the throat as well as by the severity of the illness.

Beginning of Treatment.-The hospital patients come largely from the poorer classes, where the illness is likely to be neglected at the outset and proper treatment deferred. In most of the cases treatment with antitoxin was not begun until the second or third day of the illness, and it is important to note that the large majority (at least) of the severe and fatal cases averaged four or five or more days without treatment with antitoxin.

Cardiac Signs and Symptoms.-The physical signs of a greater or less degree of cardiac disturbance, such as

murmurs, and rapid and irregular pulse, were very common. Ordinary symptoms of heart disease, such as dyspnoea, dropsy, cyanosis and hemorrhage, were not common. We will take up the physical signs first on account of their far greater frequency.

Pulse Rate.-This table shows the relation between maximum pulse rates and mortality.

PULSE RATE.

NO. OF CASES. NO. OF DEATHS. PER CENT. OF DEATHS.

About sixty-five per cent. of our cases had a maximum pulse rate of less than one hundred and forty, and the mortality among these was about five per cent. In general the higher the pulse rate the greater the mortality, as would naturally be expected. About 20 per cent. of the cases with pulse rate of one hundred and forty or over, were fatal. It is however a fact, that a prognosis from the pulse rate alone is of little value, because so much depends on the age of the patient. The pulse rate at discharge in cases which were not fatal was 100 or less in about 68 per cent., between 100 and 120 in about 31 per cent., and over 140 in five cases, or less than one per cent.

Irregularity of Pulse.-This was noted in nearly sixty per cent. of our cases, and the actual number of patients. having an irregular pulse at any time may be even larger than this. It was frequently observed in severe, moderate, and even in mild cases. It was observed at the entrance to the hospital in about 12 per cent. of the patients, often combined with cardiac murmurs. In the majority of cases its time of onset was one or two weeks after entrance, and in about 35 per cent. of the cases the heart was irregular at discharge. In about one per cent. of the patients it was the first sign of cardiac disturbance observed.