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between 90 and 120. The heart sounds were very variable with periodical softening
or muffling of the first sound at the apex. At times it was impossible to distinguish
between systole and diastole. Signs of some cardiac dilatation were present, as
was evidenced by extension of the right border of the heart upon percussion. In the
first case such signs of back pressure as an enlarged tender liver and pulsating
jugular veins were found.
Diagnosis.
Tournafond found that a few forms of cardiac arrhythmia which are not apparent
clinically are shown to be present by means of the electrocardiograph.
My cases all showed definite auscultatory phenomena, and although electrocardiographic
examination might have given further information, it was not necessary
to establish a diagnosis. Indeed, the experience of Faulkner, Place and Ohler,
who investigated by means of the electrocardiograph 171 cases of scarlet fever,
suggests that electrocardiograms are not so helpful in scarlet fever as thev are in
many other conditions. In 17 of their cases where cardiac damage could be demonstrated
by clinical examination, the electrocardiographs failed to show any
abnormality.
These arrhythmias must be distinguished from the sinus arrhythmias due to
the influence of respiratory movements or to the administration of certain drugs.
The extra-systoles were not sporadic, but were accompanied by a definite and
persistent irregularity of rhythm, the extra-systolic beats being premature, occurring
before the regular beat and being followed bv a relatively long pause.
Treatment.
Cardiac arrhythmias in scarlet fever as in other infectious diseases do not
invariably respond to specific therapeutic measures.
Salicylates were tried but did not seem to be definitely effective in any of my
cases. Rest in bed produced beneficial results, as in other cardiac affections.
Quinidine, digitalis and strophanthin were also used, of which quiniaine seemed to
produce the best results.
The first case, however, showed rapid improvement after serum injection.
Serum was given in all the cases, but its results were more particularly obvious
in this toxic example.
Prognosis.
Gushing investigating the cardiac condition following scarlet fever found 24 per
cent, with disorderly action of the heart, some of which he states persisted for five
years. But this result is unusually high, and is not the experience of any other
investigator. Faulkner, Place and Ohler examined 600 cases 1 to 3 years after
being in hospital with scarlet fever, and of these they found seven with cardiac
disease, of which only three had no antecedent history. In these three cases the
lesions were indistinguishable clinically from "rheumatic" heart disease.
The severity of the infection of scarlet fever does not always seem to bear
a direct relationship to the occurrence of arrhythmia. Apart from the first, which
was undoubtedly a severe toxic one, my cases were all of a mild nature.
In every case the arrhythmia appeared abruptly, and as abruptly cleared up.
The duration of the arrhythmias was transient, varying from two to 80 days.
The prognosis seems to be favourable. Upon discharge all the hearts seemed
normal, and it would therefore appear that, in the absence of an underlying rheumatic
basis, an arrhvthmia is not likely to lead to permanent cardiac damage.
Conclusions.
(1) In a series of 2,300 cases of scariet fever, the only instances of cardiac
arrhythmia were: one of auricular fibrillation and three of simple arrhythmia
with extra-systoles. There were no cases of heart block, paroxysmal tachycardia
or auricular flutter.
In none of these cases was there a previous history of any heart disease, or of
any disease, such as diphtheria, acute rheumatism, tonsillitis or pneumonia, which
might produce a cardiac disorder. Nor by careful questioning could any history
of "occult " rheumatism be elicited.
In addition, they were all uncomplicated by either nephritis or arthritis.
Arrhythmias are therefore rare in scarlet fever.
(2) As almost all cases at the hospital are treated by intensive serum therapy,
one must conclude that the low incidence of all forms of cardiac disorders was not