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and originate structural changes ; they determine their character,
course, and issues ; in them is the secret of disease, and, if our control
of it is ever to become greater and better, it is upon them that our
experiments must be made." 1

Another form to which I would direct attention is that of the some-
what obese woman — married or unmarried — between forty and fifty
years of age. Not infrequently these women have a marked rheumatic
tendency. Not infrequently their urine on cooling deposits an excess
of urates of uric acid. They often have slight attacks of bronchitis,
ambulatory neuralgic pains, localized dry pleurisy. When in their
usual health they can take moderate exercise without great distress.
So soon as they have any acute ailment or depletion they suffer from
marked difficulty of breathing, a gone feeling at the epigastrium, and
an inward sense of suffocation, as they express it. Usually their cardiac
action is feeble, rapid, and slightly irregular under these circumstances.
Physical examination may or may not reveal at this time a soft blowing
murmur, systolic as a rule, often heard with greatest intensity in the

i British Medical Journal, August 16, 1884, p. 312.


mitral area, but also heard at times in the left intercostal spaces above
the nipple or at the lower end of the sternum. The blood may or may
not show a moderate degree of anaemia. Duriug and after their men-
strual epochs these patients are often at their worst, and whenever the
flow is abundant their condition inspires great solicitude. They do not
always have fever when they have their slight bronchitis or pleuritic
attacks. At other times the temperature rapidly goes to 102° or even
higher, and areas of local pulmonary congestion are accurately made
out. Such cases are amenable to judicious treatment, and in the course
of ten days or two weeks very great temporary improvement will take
place. I usually give very small repeated doses of nux vomica and
strophanthus in the beginning of these attacks. I insist upon rest in
bed and frequent small quantities of liquid or easily digested food.
Where there are cough and local signs of dry pleuritis a small fly-
blister, though painful, is a sovereign remedy. Of course, the men-
strual flow when excessive should be controlled with ergot or hot

In some of these cases where there is also well-marked anaemia there
is present at times and in a more or less continuous manner a small
amount of albumin in the urine. The clinical examination of the urine
is such that I have known patients of this sort to be told that they were
suffering from nephritis, and it was essential for them to live during a
long period upon a milk diet, and to reside in an equable, dry, and rela-
tively mild climate. In these cases the albumin would at times disap-
pear, but fatigue, indiscretions of food, temporary excitement would
apparently bring back the albuminuria. I have no doubt the kidneys
were affected with chronic congestion. I am also very confident that the
hypersemia was passive rather than active, and was, in reality and
mainly under the dependence of a weak heart, quite insufficient in its
action to keep up a proper vascular tension in the renal arteries. Here,
again, judicious cardiac treatment was essential at first. With the digi-
talis or strophanthus, however, I usually combine a small quantity of
nitroglycerin, as I deem it very important to dilate the peripheral cir-
culation and thus lessen the necessary work of the heart to become

There is another type of woman, and she is usually thin and nervous
about the time of the climateric or past it. The menstrual flow if it
still exists is slight. These patients may not be anaemic to any appre-
ciable extent. They have frequently very imperfect digestive assimila-
tion. They may have some dilatation of the stomach, and are frequently
nauseated and unable to take even the simplest forms of food for a time
without causing great and rapid gaseous distention, not only of the
stomach, but also of the bowels. The liver is inactive and the bowels
are torpid. We can give few medicines by the mouth except stomach-


ica and carminatives without making their condition worse. Although
their heart is extremely feeble, so much so at times in fact that we dread
almost to move or raise them to make a proper exploration of the chest,
yet if we so much as try to use any medication by the mouth to
strengthen heart action we shall almost surely bring on worse distress
and perhaps' excessive nausea and repeated vomiting. I have been
obliged to treat such a patient for days at a time with digitaline and
strychnine hypodermatically, while inhalations of oxygen were fre-
quently administered. Rectal alimentation with panopepton, pepton-
ized milk, egg, brandy, and a little opium at times took the place
almost entirely of feeding by the mouth for several days. Where the
repeated use of the hypodermatic syringe set up local irritation I was
obliged to incorporate my cardiac stimulants with very small rectal
enemata of water. Finally, after weeks of anxiety and constant nurs-
ing and unremitting attention, these women slowly regained their health
and strength, and the heart became sufficiently strong to satisfy ordi-
nary demands made upon it when the patient went about in a very
limited measure. The urine never, upon repeated examinations, showed
either albumin or sugar, but did show low specific gravity, deficient
elimination of urea, and perhaps a few hyaline or granular casts. I
could not positively affirm any general arterio-fibrosis. I could and
did strongly suspect its presence. The heart gave all the evidences of
slight dilatation of the ventricular cavities, but at no time was there
any manifest hypertrophy. In some patients there was rarely any
cardiac murmur, and all I could detect, as a rule, was great feebleness
of heart action without irregularity or intermissions. I have no doubt,
for my part, that if these hearts were examined post-mortem they would
show few or no changes other than those which follow. They would be
soft and flabby. They would not retain their rounded, globular form,
but would flatten on the table through partial collapse of the walls.
There would be no valvular changes. The orifices might be slightly
dilated. There would be, as stated already, slight enlargement of the
cavities and thinning of the muscular walls. The color of the heart
muscle would approximate that of the faded leaf; perhaps, usually it
would only be relatively pale and bloodless. The cavities would con-
tain small, imperfectly-formed post-mortem clots or liquid blood. Under
the microscope we should find the strise here and there imperfectly
marked. There would possibly be some well-marked granular degenera-
tion at times, and only very rarely the evidence of fatty degeneration.
If the latter existed it would more likely be in patches in the capillary
muscles, the septum, or the ventricular walls than generally diffused.

Unfortunately, these are at best clinical impressions rather than well-
ascertained facts. And why ? Simply because post-mortem examina-
tions of these cases are not made. The patients do not die, in my expe-


rience, at least outside of hospitals. In hospitals, when they die, they
have more advanced and graver phenomena of a similar condition, and
then it is we can surely and positively affirm what our findings are.

In many instances I have had a report from the pathologist which in
its main features was not unlike what I have attempted to describe. In
this connection I would refer to a paper of Dr. Danforth, of extreme
interest to me, read at the last meeting of this Association, on " Clinical
Forms of the Uric-acid Diathesis." It seems to me that some of Dr.
Danforth's cases may have been mainly instances of cardiac dilata-
tion, in which the renal manifestations were merely a resultant of a weak,
feeble heart action. At all events, I have portrayed the other side of a
clinical picture frequently encountered by myself. I do not wish to con-
vey the impression that I have made a new discovery — such cases as
mine are met with by all of you. They are also described more or less
perfectly in almost every text-book of cardiac disorders of the last fifty
years. Still I am free to confess that I do not know precisely where you
will find the clinical picture I have endeavored to delineate in quite
the same terms.

I may be asked whether I do not find these cases also among men.
Perhaps I do, but I do not recall them in such a vivid manner as to be
able to portray them. The laboring man, even though he may never
suffer from actual valvular disease, will undoubtedly have at times
marked cardiac dilatation. But usually there is more or less hyper-
trophy combined with it, and, even though the heart has become very
incompetent through structural weakness, there will be such considerable
enlargement that we feel confident that the autopsy will show more or
less thickening of heart walls. The same is true of old valvular disease
accompanied with cardiac enlargement. It is equally true, as a rule,
where the history shows that there has been a persistent and excessive
alcoholic habit. This is true also, although in less degree, of the busi-
ness or professional man affected with heart disease.

Extreme cases of heart dilatation and no hypertrophy are also met
with among men ; but the minor degrees, those to which I have referred
and tried to describe, are usually found among women. The intense
heart failure, coming on rapidly, almost suddenly at times among men,,
and unquestionably due to very great cardiac dilatation, against which
the heart is almost powerless to react, is sometimes seen after great
excesses. These cases, as we all know, may be rapidly or suddenly fatal
despite our most active means of resuscitation. Among these cases,
however, are unquestionably some in which the physical signs of cardiac
dilatation are impossible to determine accurately. I can, therefore, well
understand that their existence should be denied. In place of such a
diagnosis I cannot but substitute one of loss of nerve-power, either in
the intracardiac ganglia or in the trunks of the vagi. To admit this


would be perhaps also to acknowledge that the heart muscle was intact
and the cavities of normal dimensions. Such a belief would be strength-
ened by those instances in which certain cardiac tonics, and especially
digitalis, are of little apparent value, perhaps, indeed, directly injurious,
and rest in bed and suitable liquid diet with alcoholic stimulants appear
to be most useful.

Again, there are instances in which there is certainly no pronounced
structural kidney change, where we watch closely the sequence of clinical
phenomena. There is renal inadequacy only. The secretion of healthy
urine, viz., of normal color, density, in sufficient quantity aud without
abnormal constituents, after a few days or weeks of rest, and when the
patient is given easily assimilable food, returns, and our temporary fears
are allayed. In some cases I recognize a possible spasmodic condition
of the peripheral vessels and especially of the kidneys. We have inti-
mation of this by high pulse tension at times and the rapid good effects
of repeated small doses of nitroglycerin. Occasionally I have seen
cases in which the heart action was very feeble, without any accentua-
tion of the aortic second sound, and where the radial pulse itself had no
increased tension, and yet nitroglycerin was of undoubted service, for
after its use the heart's action was notably improved, and the secretion
of urine, from being almost colorless and even small in quantity took
on its normal appearance and character. No doubt the nitroglycerin
acted as a direct heart tonic to the cardiac muscle itself; no doubt, also,
it dilated the small vessels of the kidney, breaking up any spasmodic
condition that existed, and thus was of very great benefit to the patient.
At all events, I have certainly seen nervousness, marked twitching of
the muscles, apathy, and somnolence — all symptoms, as I believe, indi-
cating more or less so-called ursemic poisoning — disappear and the
patient progressively improve until fairly good health and strength
were established. Examples of this kind are not uncommon, I believe
as a resultant of what has appeared to be a grippal attack.

Through a contribution to the London Lancet in October, 1899, by
A. E. Sansom, I am of the opinion that he, also, has seen cases not dis-
similar. Cohnheim and Leyden have intimated that occasionally the
underlying cause of ursemic symptoms is found in cardiac insufficiency.
Hence the blood stagnates in the renal vessels. Clinical observations on
contracted kidneys support this view, as does the use of cardiac stimu-
lants for the relief of their manifestations.

From the point of view of prognosis the character of the pulse is
often very important. "When it is relatively weak and perhaps irregu-
lar the outlook becomes serious. Sir William Broadbent has pointed
out the gravity of a pulse of low tension when accompanied with symptoms
indicating possible cirrhosis of the kidney. I have frequently had
occasion to make a similar observation. No doubt many of these cases,


however, merely enter into the category of what Sir Andrew Clark has
described as " renal inadequacy " accompanied with some degree of cardiac
dilatation. These are a class of cases in which, although the kidney
presented no alteration of structure, it was unable to produce a per-
fectly healthy urine. In these cases the urine is low in density and
deficient in solid constituents, principally in urea and its congeners. 1

I might lengthen this paper considerably. I prefer not to do so, as I
very much desire a discussion from the members of the Association as to
its value and truth.

1 Albuminuria and Bright's Disease, by M. Tirard, London, 1899, p. 16.


One of the most interesting and also difficult subjects connected with
cardiac pathology is that of inflammation of the muscular walls.
Formerly, as we know, the existence of this affection was denied, or, if
admitted by some authors, had relatively small importance as compared
with inflammation of the endocardium or pericardium. At a later date in
the history of cardiac disorders myocarditis commenced to assume some
importance. It is only, however, within a brief period that the different
affections of the muscular structure of the heart have received their true
value and consideration. I am glad to state at present that the
medical mind has had an awakening, and to those who are careful
observers and clinicians the mere presence of a murmur or a pericar-
dial friction-sound is no longer of great moment unless it carries with it
the probability that sooner or later real functional disability will occur
owing to its effects upon the adjacent muscular walls. Of course, the
effects of muscular changes must depend largely upon many conditions.
The causation is different ; the circumstances in which they occur are
manifold, and may be acute or chronic, limited or diffuse.

In acute diseases, especially those affecting the whole organism, and
mainly those of febrile type, we have to do with the most interesting
and most important cases, because our time is limited to act properly
and efficiently, and the threatening is often imminent, although the
indications may be obscure and our useful interference be questionable.
Mere doing is by no means so imperative as well doing. Life often
hangs in the balance, and immediately so.

In the eruptive fevers — in diphtheria, typhoid fever, pneumonia, rheu-
matism, in many septic conditions, in toxic states, and, above all, acute
alcoholism at times — how often do we stand at the bedside and ask, Is
this a case where the muscular fibre of the heart is already touched by
the poison of the disease to the degree where acute degeneration is
already present? Unquestionably there are times when the closest
observation and attention on our part will still leave us in great and
anxious doubt. Other instances present themselves in which we feel
that we are reasonably sure in our judgment and are quite confident
that no other diagnosis is sufficient or permissible to explain symp-
toms and signs satisfactorily unless it be inflamed or degenerated
cardiac muscle.



In many instances of typhoid fever and diphtheria of marked viru-
lence and intensity in which the general symptoms have been alarming
almost from inception of the disease, in a very brief period, or about
the fourth, fifth, or sixth days, we occasionally remark a feeble and
very rapid heart action. The first sound may be low, distinct, muffled ;
the second sound may be somewhat accentuated and particularly over
the pulmonary area, or, again, this sound, although still distinct, lacks
force and normal intensity. With such a heart we have a rapid, feeble
pulse, small in volume, and easily depressible ; it may be unequal,
somewhat irregular ; a beat may now and then be lost or inappreciable
to our tactile sensations. Instead of a rapid heart we may have a slow
one ; but this is rare, almost exceptional in these acute cases. A soft,
blowing murmur at the apex and systolic in time is often developed.
It may be limited as to its area or it may be widely heard over the
prsecordia. While this is true, it is still heard most intensely near the
apex-beat or in the pulmonary area. In the latter case a pulsation of
the second and third left intercostal spaces may accompany it; and
this pulsation is of itself, as Russell has noted, an evidence of some
degree of heart failure. Restlessness, profuse perspiration, especially
of the face and upper limbs, accompany this condition. The patient is
apathetic, listless, soporose, or frequently there is a low, muttering de-
lirium from which he can be separated for a moment only by acquiring
his attention with forcible and loud questioning. With such a cardiac
state we may or may not have more or less implication of the bronchial
tubes or lung structure ; and dulness at the bases with fine crepitation
during inspiration and over an area of at least a hand's breadth is no
uncommon finding. The urine is apt to be somewhat deficient as to
quantity and to contain abundant urates, an occasional cast, hyaline or
granular, and a notable amount of albumin.

Cases like the foregoing, in diphtheria especially, are apt to terminate
fatally and often suddenly. This is also true of croupous pneumonia.
In typhoid fever they may go along about in the same way for several
days and then perhaps measurably improve. Such cases even in
typhoid fever are prone to be long and severe ones, and it is frequently
difficult to say positively what the ultimate outcome will be, even
though no other dangerous complication may subsequently arise.

What is the pathology of such a condition ? In the few rare in-
stances where I believe I have seen it at the autopsy, very little at
times that is positively indicative of muscular changes. It is true the
heart is soft and flabby ; it tears more easily than it should ; it is
darker in color, probably from blood-staining; heart clots are few,
badly formed, and usually cruoric in typhoid fever.

In pneumonia and diphtheria, on the contrary, they are often in
large part fibrinous, sometimes gelatinous-looking, sometimes with the


fluid well pressed out of them, and almost appear to have several layers
of superimposed fibrin. Extensions of the clot are not uncommon in
the pulmonary artery, and they often fill moderately the right ventric-
ular cavity and auricle. The heart may be somewhat enlarged, but
where this is the case I have attributed it to previous disease. In a
similar way where there has been any very manifest valvular trouble
I could not believe that the acute trouble had anything to do with it.

I shall make an exception for a certain degree of vascularization of
the mitral valve which I have seen more than once. In diphtheria
notably there is often a decided beading, with redness, swelling, and in-
creased vascularity of its free margin. The other valves are usually
normal, at least to the naked eye. Under the microscope the cardiac
fibres present little or nothing abnormal ; here and there, perhaps, there
may be a slight granular condition, and the stria? may not be so distinct
as normal.

In those instances in which I have seen autopsies later on in the
course of acute disease of febrile type — and I am now speaking particu-
larly of typhoid fever, pneumonia, and diphtheria — I have occasionally
seen areas of the heart muscle either in the papillary muscles or in the
walls of the ventricles which seemed paler to the naked eye than the
rest of the heart. In these areas without doubt there was a deposit of
fat — microscopical sections have later revealed decided fatty degenera-
tion at least in limited areas ; and when that is the case not only the
nuclei of muscle may be much changed in form and structure, but
the heart fibres otherwise show the degeneration. The striation of some
fibres may have almost completely disappeared, the granulations may
be very numerous, interspersed with many fat globules, and the inter-
stitial cellular tissue between the primitive muscular bundles may be
notably increased, besides containing many red or white blood-cells.

I confess there is no direction in which this inflammatory and perhaps
degenerative development interests me more than in croupous pneu-
monia. The reason is not far to seek. In no other acute disease does
life terminate more frequently, suddenly, and at times unexpectedly
from so-called " heart failure " than it does here. Now what is this
due to unless it be through the myocardial inflammation or degenera-
tion which has become developed under the poison of the disease? And
this is proved particularly when we encounter those instances of very
limited or partial lung involvement, and yet they march steadily from
bad to worse despite our every effort made to save them.

Up to the present time we have no drug or system of medication
that is in any way satisfactory to meet these cases. The nearest approach
to it, in my judgment, is to respond to the indications in the following
manner : on the one hand, to help restore lowered nerve tone and
strengthen muscular activity with frequently repeated and even large


doses of strychnine ; and, on the other, to destroy or neutralize the
pernicious effects of bacterial invasion of lung tissue, and thence the
blood and whole organism, with inhalations mainly antiseptic in char-
acter, of which I still believe beechwood creosote is the best, though
very imperfect, of which we have knowledge. I have not been able to
appreciate that the use of heart tonics like digitalis and strophantus,
in anything except small, repeated doses, and then only in a very tem-
porary manner, has proved to be really useful. Nor, indeed, with the
recognized pathology of the bad cases of pneumonia, diphtheria, or
typhoid fever do I see how they could be.

It always seems to me as though the great risk of producing such
forcible contraction of the relatively healthy fibres as to effect cardiac
dilatation through distention of those which are more or less degen-
erated neutralized all useful action. This is no mere baseless theory.
It is a conviction forced upon me by close, attentive clinical observa-
tion and inquiry.

I believe that the poisonous effects of these diseases, certainly so far
as the heart is concerned, in many instances, are more or less self-
limited. This being admitted, our effort should be to avoid, above all,
doing more or less irretrievable harm, and that, too, in a very rapid
manner. In many of these cases I am confident we do much less harm
when we guard our use of digitalis and strophanthus with nitroglycerin
or the nitrites. Thus we break up peripheral resistance as much as
may be, and so we lessen the necessity of the heart doing more work
than it can possibly perform. The diffusible stimulants are the medi-
cines which are most clearly indicated and many times urgently re-
quired. Alcohol, ammonia, ether, chloroform, camphor — all these are
good and at least rarely give us cause for regret.

There is one drug which I feel at present is far less used in these

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Online LibraryBeverley RobinsonEssays on clinical medicine → online text (page 10 of 20)