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Penicillin therapy of scarlet fever
622
AMERICAN
were misdiagnosed. (levoangiocardiogram), greatly increased.
With
the further the chances
extension of correct
HEARTJOURNAL of this diagnostic procedure by Steinberg diagnosis of anatomic defects of the heart
and Robb have been
W.-L. <&.I GOLD.
Bell,
F. K., Carr, codynamics
C. J., and of Diginin.
Krantz, J. C. : Digitalis J. Pharmacol. (0, Exper.
V. The Therap.
Baljet 89:143
Reaction (Feb.),
and
Pharma-
1
In 1937, Karrer isolated a new glycoside from the leaves of Digita& purpure It differs from the other glycosides in that it is not a lactone. It was reported as having little cardiotonic activity. Its presence, in significant amounts, appeared to be an obstacle to the assay of digitalis preparations by the colorometric method based upon the Baljet reaction (glycosides, in the presence of an excess alkaline sddium picrate, develop a red color). Hagemeier reported a high color intensity for diginin. Solutions of diginin in absolute methanol were tested in concentrations of from 5 to 30 mg. per 100 cubic centimeters. They showed low color values when compared to digitoxin on either a weight or a molar basis. Plotted on a basis of molar concentration, diginin gave colorometric readings approximately one-third those of digitoxin. The significance of diginin in standard preparations, bioassayed by the Beljct reaction, is limited. It must be assumed that the LT. S. P. preparations contain significant amounts of this glycoside. When unknowns are compared to U. S. I’. standards, it would take a large discrepancy of diginin content to cause a significant error. Diginin was found, to have very little cardiotonic action in both cats and dogs. Large quantities (ten times more than digitoxin) were necessary to cause death. GODFREY. Kissane, R. W., Fidler, Disease. Preliminary
R. S., and Report.
Clark, T. E.: Liver Dysfunction Am. J. M. SC. 213:410 (April),
in Rheumatic 1947.
Heart
The cephalin-cholesterol flocculation reaction was found positive in 72 per cent of 136 cases of rheumatic heart disease. Neither the valvular lesion, age of the patient, nor the length of time rheumatic heart disease had existed seemed to effect any variation from the percentage of positives in the entire group. Also, there was no correlation between the degree of positive reaction and the degree of functional severity of rheumatic heart disease. DURANT. Blumberg, phalein
N., and Schloss E. M.: Test in Liver Disease.
The Effect of Circulatory Am. J. M. SC. 213:470 (April),
Factors 1947.
on
the
Bromsul-
Evidence is presented that two factors may be concerned in the mechanism of bromsulphalein retention: hepatic excretory dysfunction, and circulatory inadequacy. There does not appear to be any present method for delineating the proportion of influence to be assigned to each factor where both are operative in the same patient. However, the data suggest the advisability of performing studies of circulatory integrity in those cases of liver disease in which there is clinical evidence of concomitant cardiovascular involvement. While it is evident that those instances in which such circulatory studies are abnormal will fail to indicate the proportion of abnormal cfye retention due to either factor, it is equally true that those in which circulation time and venous pressure are normal will present confirmation that the abnormal bromsulphalein retention can then be attributed solely to hepatic dysfunction. DURANT. Hirsch, H. L., of Scarlet
Rotman-Kavka, Fever. J.A.M.A.
G., Dowling, H. F., and 133:657 (March 8), 1947.
These authors treated eighty-six patients with scarlet penicillin G and commercial penicillin. The first thirty-four X and five patients were treated with penicillin G. Thereafter, commercial penicillin in doses of 25,000 units every 3 hours,
Swee,
L. K.:
Penicillin
Therapy
fever with penicillin X, crystalline patients were treated with penicillin alternate patients were given either or 9,000 to 27,000 unitsof antitoxin,
SELECTED
ABSTRACTS
623
depending on the degree of toxicity. A group of eighteen patients received oral penicillin in a dose of 125,000 units every three hours. These authors established five days as a minimum period of treatment for scarlet fever. Penicillin therapy resulted in a prompt fall in temperature, a decrease in toxicity, a decided reduction in the incidence of pyogenic complications, and practically eliminated the carrier state. Penicillin was more effective than antitoxin or symptomatic therapy in the prevention of complications and in reducing the number of carriers and was equally effective in decreasing toxicity. Antitoxin caused a more rapid decline in temperature than did penicillin. However, temperature dropped more rapidly in patients given penicillin than in symptomatically-treated patients. These authors feel that a further advantage of penicillin over antitoxin in the routine treatment of scarlet fever is the elimination of the frequent occurrence of serum sickness following the use of antitoxin. They also state that severely toxic patients should receive antitoxin in addition to penicillin.
BELLET. Levine, S. A., and Geremia, A. E.: Cl inical Special Reference to Cardiac Murmurs.
Features of Patent Ductus Arteriosus Am. J. M. SC. 213:385 (April), 1947.
With
The accurate diagnosis of congenital heart disease is no longer a purely academic or intellectual endeavor now that modern surgery has made possible the successful treatment of certain types of such disease. Realizing this fact, the authors have made a very thorough study of thirty-seven verified cases of patent ductus arteriosus, with special emphasis on the auscultatory findings before and after operation. The first interest was the intensity of the murmur. In twenty-five patients in whom accurate estimation by a competent observer was made preoperatively, the average intensity of the systolic component was found to be Grade 4; in eleven, Grade 3; and in one, Grade 2. In twenty-one instances the intensity of the diastolic component was carefully noted preoperatively and the average was found to be Grade 3. In no instance was the diastolic component louder than the systolic. In five patients it was faint enough to be called Grade 2, and in one instance it was considered to be only Grade 1. There was no instance in the series in which no murmur could be heard at all, although in one instance it disappeared during the last month before death. The murmur was generally loudest in the pulmonary area. When very loud it was widely distributed, being heard in the interscapular area and even, at times, as far down the arm as the olecranon process. Apical systolic murmurs were always present, and in some patients the continuous systolic and diastolic murmur were also heard, though fainter, at the apex. In four patients a definite mid-diastolic murmur, unlike the pulmonic murmur and resembling the murmur of mitral stenosis, was heard. A definite palpable systolic thrill was present in twenty-one of the thirty-seven cases, and was maximal in the second and, occasionally, in the first left intercostal space. It was always systolic in time but occasionally extended well into diastole The most significant observation in the postoperative study was the fact that a slight pulmonic systolic murmur may persist for a considerable time after successful division of the ductus. Such basal systolic murmurs may possibly be explained on the basis of continued dilatation of the pulmonary artery, or may have the same debatable significance ascribed to other inconsequential or functional basal systolic murmurs. The occasional persistence of a basal systolic and diastolic murmur may be interpreted in one of several ways: namely, recanalization of the duct (when it has been ligated but not divided), the presence of bacterial endocarditis of the aortic valve, or an additional anatomic lesion, such as coarctation of the aorta or some other congenital abnormality. A review of the blood pressure readings confirmed the fact that the pulse pressure is increased in patent ductus arteriosus and that the levels return to normal after treatment. The average systolic pressure was not altered by operation, but the average diastolic pressure rose 20 millimeters of mercury. In the thirty-four cases in which preoperative electrocardiograms were available, four showed left axis deviation; only one showed right axis deviation. The electrocardiogram, therefore, proved to be indirectly helpful in diagnosis since right axis deviation is very common in various other forms of congenital heart disease.
AMERICAN
were misdiagnosed. (levoangiocardiogram), greatly increased.
With
the further the chances
extension of correct
HEARTJOURNAL of this diagnostic procedure by Steinberg diagnosis of anatomic defects of the heart
and Robb have been
W.-L. <&.I GOLD.
Bell,
F. K., Carr, codynamics
C. J., and of Diginin.
Krantz, J. C. : Digitalis J. Pharmacol. (0, Exper.
V. The Therap.
Baljet 89:143
Reaction (Feb.),
and
Pharma-
1
In 1937, Karrer isolated a new glycoside from the leaves of Digita& purpure It differs from the other glycosides in that it is not a lactone. It was reported as having little cardiotonic activity. Its presence, in significant amounts, appeared to be an obstacle to the assay of digitalis preparations by the colorometric method based upon the Baljet reaction (glycosides, in the presence of an excess alkaline sddium picrate, develop a red color). Hagemeier reported a high color intensity for diginin. Solutions of diginin in absolute methanol were tested in concentrations of from 5 to 30 mg. per 100 cubic centimeters. They showed low color values when compared to digitoxin on either a weight or a molar basis. Plotted on a basis of molar concentration, diginin gave colorometric readings approximately one-third those of digitoxin. The significance of diginin in standard preparations, bioassayed by the Beljct reaction, is limited. It must be assumed that the LT. S. P. preparations contain significant amounts of this glycoside. When unknowns are compared to U. S. I’. standards, it would take a large discrepancy of diginin content to cause a significant error. Diginin was found, to have very little cardiotonic action in both cats and dogs. Large quantities (ten times more than digitoxin) were necessary to cause death. GODFREY. Kissane, R. W., Fidler, Disease. Preliminary
R. S., and Report.
Clark, T. E.: Liver Dysfunction Am. J. M. SC. 213:410 (April),
in Rheumatic 1947.
Heart
The cephalin-cholesterol flocculation reaction was found positive in 72 per cent of 136 cases of rheumatic heart disease. Neither the valvular lesion, age of the patient, nor the length of time rheumatic heart disease had existed seemed to effect any variation from the percentage of positives in the entire group. Also, there was no correlation between the degree of positive reaction and the degree of functional severity of rheumatic heart disease. DURANT. Blumberg, phalein
N., and Schloss E. M.: Test in Liver Disease.
The Effect of Circulatory Am. J. M. SC. 213:470 (April),
Factors 1947.
on
the
Bromsul-
Evidence is presented that two factors may be concerned in the mechanism of bromsulphalein retention: hepatic excretory dysfunction, and circulatory inadequacy. There does not appear to be any present method for delineating the proportion of influence to be assigned to each factor where both are operative in the same patient. However, the data suggest the advisability of performing studies of circulatory integrity in those cases of liver disease in which there is clinical evidence of concomitant cardiovascular involvement. While it is evident that those instances in which such circulatory studies are abnormal will fail to indicate the proportion of abnormal cfye retention due to either factor, it is equally true that those in which circulation time and venous pressure are normal will present confirmation that the abnormal bromsulphalein retention can then be attributed solely to hepatic dysfunction. DURANT. Hirsch, H. L., of Scarlet
Rotman-Kavka, Fever. J.A.M.A.
G., Dowling, H. F., and 133:657 (March 8), 1947.
These authors treated eighty-six patients with scarlet penicillin G and commercial penicillin. The first thirty-four X and five patients were treated with penicillin G. Thereafter, commercial penicillin in doses of 25,000 units every 3 hours,
Swee,
L. K.:
Penicillin
Therapy
fever with penicillin X, crystalline patients were treated with penicillin alternate patients were given either or 9,000 to 27,000 unitsof antitoxin,
SELECTED
ABSTRACTS
623
depending on the degree of toxicity. A group of eighteen patients received oral penicillin in a dose of 125,000 units every three hours. These authors established five days as a minimum period of treatment for scarlet fever. Penicillin therapy resulted in a prompt fall in temperature, a decrease in toxicity, a decided reduction in the incidence of pyogenic complications, and practically eliminated the carrier state. Penicillin was more effective than antitoxin or symptomatic therapy in the prevention of complications and in reducing the number of carriers and was equally effective in decreasing toxicity. Antitoxin caused a more rapid decline in temperature than did penicillin. However, temperature dropped more rapidly in patients given penicillin than in symptomatically-treated patients. These authors feel that a further advantage of penicillin over antitoxin in the routine treatment of scarlet fever is the elimination of the frequent occurrence of serum sickness following the use of antitoxin. They also state that severely toxic patients should receive antitoxin in addition to penicillin.
BELLET. Levine, S. A., and Geremia, A. E.: Cl inical Special Reference to Cardiac Murmurs.
Features of Patent Ductus Arteriosus Am. J. M. SC. 213:385 (April), 1947.
With
The accurate diagnosis of congenital heart disease is no longer a purely academic or intellectual endeavor now that modern surgery has made possible the successful treatment of certain types of such disease. Realizing this fact, the authors have made a very thorough study of thirty-seven verified cases of patent ductus arteriosus, with special emphasis on the auscultatory findings before and after operation. The first interest was the intensity of the murmur. In twenty-five patients in whom accurate estimation by a competent observer was made preoperatively, the average intensity of the systolic component was found to be Grade 4; in eleven, Grade 3; and in one, Grade 2. In twenty-one instances the intensity of the diastolic component was carefully noted preoperatively and the average was found to be Grade 3. In no instance was the diastolic component louder than the systolic. In five patients it was faint enough to be called Grade 2, and in one instance it was considered to be only Grade 1. There was no instance in the series in which no murmur could be heard at all, although in one instance it disappeared during the last month before death. The murmur was generally loudest in the pulmonary area. When very loud it was widely distributed, being heard in the interscapular area and even, at times, as far down the arm as the olecranon process. Apical systolic murmurs were always present, and in some patients the continuous systolic and diastolic murmur were also heard, though fainter, at the apex. In four patients a definite mid-diastolic murmur, unlike the pulmonic murmur and resembling the murmur of mitral stenosis, was heard. A definite palpable systolic thrill was present in twenty-one of the thirty-seven cases, and was maximal in the second and, occasionally, in the first left intercostal space. It was always systolic in time but occasionally extended well into diastole The most significant observation in the postoperative study was the fact that a slight pulmonic systolic murmur may persist for a considerable time after successful division of the ductus. Such basal systolic murmurs may possibly be explained on the basis of continued dilatation of the pulmonary artery, or may have the same debatable significance ascribed to other inconsequential or functional basal systolic murmurs. The occasional persistence of a basal systolic and diastolic murmur may be interpreted in one of several ways: namely, recanalization of the duct (when it has been ligated but not divided), the presence of bacterial endocarditis of the aortic valve, or an additional anatomic lesion, such as coarctation of the aorta or some other congenital abnormality. A review of the blood pressure readings confirmed the fact that the pulse pressure is increased in patent ductus arteriosus and that the levels return to normal after treatment. The average systolic pressure was not altered by operation, but the average diastolic pressure rose 20 millimeters of mercury. In the thirty-four cases in which preoperative electrocardiograms were available, four showed left axis deviation; only one showed right axis deviation. The electrocardiogram, therefore, proved to be indirectly helpful in diagnosis since right axis deviation is very common in various other forms of congenital heart disease.