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acute cases than it should be, and that is iodide of potassium. Its effect
in stimulating the nerve centres, especially when the febrile stage has
lasted more than a few days, is perhaps known to a few, but is not yet
sufficiently insisted upon. Later, of course, and wherever other means
have failed us, and particularly wherever we dread the formation of
interstitial growth between cardiac fibres, already many good observers
acknowledge its value and rely upon its use more than any other drug.

With respect to oxygen, opinions are various. Some there are who,
despite frequent use of oxygen, affirm that it has little or no value.
Others there are who believe, and I am now more and more firmly fixed
in this opinion, that provided we give oxygen in its pure form, modified
only by a small proportion of nitrous monoxide, freely and more or less
continuously during the stress of the acute disease, we shall be able
frequently to ward off or prevent the calamitous effects of the bacterial
poison in effecting cardiac degeneration and notably that which is fatty.


In addition to the foregoing I feel called upon to refer to the use of
cold in pneumonia only to speak of it in measured terms of praise.
While I have little doubt that in some instances a moderately cold
compress, properly applied around the chest, may be serviceable in re-
lieving pain, oppression, and lowering temperature, I do not believe
that we usually obtain the stimulating effects upon the cutaneous cir-
culation and toning up of the central nervous system which has been
ardently claimed for it. I am rather of the opinion that similar good
effects may be obtained from moderate warmth.

No doubt the old fashioned poultice of meal or flaxseed was dirty,
cumbersome, and unnecessarily troublesome to the patient and nurse ;
no doubt, also, by its frequent change it fatigued the patient often very
much, and yet it did soothe and relieve. We shall obtain these good
effects from lukewarm water covered with impermeable material, which
retains heat and moisture and without being a source of anything like
the same degree of annoyance.

I know these are heterodox views to many ; I know that the stimu-
lating effects of cold on the cutaneous circulation and central nervous
system are most ably advocated by a few, and in this connection I
should be derelict not to mention the name of Dr. Simon Baruch, who
has done so much to explain and to fortify those who hold to the great
advantages of cold externally and internally employed.

I must confess it always seems to me when a patient's nervous system
is already suffering intensely from profound systemic poisoning and
when degenerative processes are, without doubt, in a sure way of being
developed, that what we need especially is to soothe rather than to
stimulate, unless with our stimulation we afford the food that is most
readily disposed of as fuel ; and such, I take it, is essentially the role
of alcohol and the ethers in severe acute febrile disease.

Why is it when all other means fail do we almost invariably have
recourse to the soothing and stimulating effects of morphine hypoder-
matically, or, better still, sometimes small doses of extract of opium
internally? Here, again, I believe our useful interference must of
necessity be a very measured one. Pass by the narrow limit, and we do
irretrievable harm ; but no one can deny when a heart is weakened to
its utmost, when urinary secretion is very small and concentrated, that
many, many times such patients are marvellously relieved in every way
by the use of these drugs. I have repeatedly seen the heart beats
lessened in frequency and gain in strength and regularity. I have
also seen the urinary secretion become more abundant and resume all
its normal characters.

The question of the application of cold, of course, is often a relative
one ; but what I claim is that the application of a compress soaked and
wrung from water at 90° to 95° F. does just as much and more good


than the compress applied from water at 65° or 70° F. Very soon
the compress will reach the former or even a higher temperature when
the body is at 103° to 104° F. or still higher, and surely the discomfort
and risks resulting from brief, temporary shocks to the nervous system
which frequently repeated cold compresses mean are not to be lightly

As to the cold bath in pneumonia, even the most enthusiastic of the
advocates of its use has abandoned it whenever an adult pneumonia
is treated (see Medical Record, August 4, 1900, article by Simon Baruch),
and finally reserves it solely for certain cases of pneumonia in children.
I am fully prepared to admit in this question of the utility of cold ap-
plications in pneumonia that here as everywhere in the practice of
medicine allowance must always be made for personal idiosyncrasy and
epidemic influence. There are a few patients who do bear cold appli-
cations apparently well, without much harm resulting, and occasionally
with seeming good effects.

There are also seasons in which pneumonias — despite seeming viru-
lence, it may be, at the start or in the initial stage — do not later show
at all the same virulence as we have seen at other times and under
seemingly like conditions. Why this is will not be satisfactorily under-
stood until susceptibility to disease and the intimate laws which govern
it are far better understood than they are by us today.

It must be always borne in mind in the care of these cases how essen-
tial it is to prevent as far as possible all exertion on the part of the
patient. The nurse should see to it that whenever a change of position
is desirable she should aid him as far as she can ; even the raising of
the head in the voluntary act of drinking should be assisted. An
alarming or fatal attack of syncope may possibly occur unless attention
be thus rigidly exercised. Frequently repeated and easily assimilable
nutrition should be kept up with beef peptonoids, milk, koumyss, broths,
egg-nog, etc.

In more than one instance I have felt assured that I have helped my
patient's condition markedly by giving an ounce or more of black coffee
by the mouth several times in twenty-four, hours, or a stimulating
enema of coffee per rectum in much larger quantity if there was evident
great prostration, sudden collapse, or pronounced stomachal intolerance.

Later on in the course of acute febrile diseases sudden death from
heart failure due to myocarditis is not very infrequent. I have known
it to occur in diphtheria when the outlook had appeared relatively
favorable and when the convalescent stage was almost reached. I
have also had at least one sad experience of it with a child recovering
apparently from typhoid fever. In many instances I have had little or
no doubt that owing to acute degeneration of cardiac muscular fibres
death occurred which might otherwise have been averted.


In these cases there have been areas of the papillary muscles or of
the left or right ventricular walls where the yellow coloration, soft,
friable tissue and perhaps greasy feel gave to the naked eye positive
indications of what the microscope would surely reveal, viz., more or
less complete disappearance and fatty degeneration of muscular fibres.

It is reported by several reliable observers that they have found also
hyperplasia of connective tissue between the fibres, with numerous leu-
cocytes, red cells, and proliferative cells. Pigment granules, regularly
or irregularly disseminated within and between muscular fibres, have
been frequently observed. This change, especially as regards quantity,
is more apt to occur the older the patient is. The cells, both of muscle
fibre and cellular tissue, are much changed in form and structure or
may have disappeared altogether. It is also true that horizontal stria-
tum of muscle and the long fibrillation often no longer exist in parts.
The muscular fibre maybe almost hyaline in appearance and relatively
broad. It may be also atrophied and diminished in size owing to the
pressure and contraction exerted by connective tissue increase. The
latter change, however, is one much more frequently met with in
chronic myocarditis, where almost all changes, according to some writers,
partake of this character and make a real fibroid degeneration of the
cardiac muscle.

We should not expect to find fatty changes always widely dissem-
inated or deeply seated. Frequently these changes are merely in
patches, and elsewhere the cardiac fibre is apparently and relatively
healthy so far as the microscope reports. Even in the midst of a local
degeneration of tissue certain fibres are much more affected than others,
and alongside of one fibre which is almost wholly granular or fatty
another will be found nearly intact.

In those cases where there is accompanying endocarditis or pericar-
ditis the degeneration is apt to be much more diffuse than where no in-
flammatory condition of these membranes exists. The papillary muscles
and the ventricles, especially the left near the apex, are the parts usually
most degenerated. The auricles are very rarely at all notably involved.

In many of these cases, although the symptoms and signs during life
pointed with great certainty toward probable degeneration of muscular
cardiac fibre, we are surprised at the autopsy to find little or no evidence
of it. Beside, the valves and orifices are usually intact ; at least there
is no evidence of acute inflammation or old sclerotic changes. The
heart, however, is soft, flabby, has lost its shape, flattens out when rest-
ing on the table ; the walls are sometimes somewhat thinner than normal
and the cavities slightly increased in size. In such cases when the right
or left ventricle is opened at the apex and the hydrostatic test made the
valve is not competent.

Two facts are thus explained to my mind which have been recognized


during life : first, functional disability ; second, a soft, blowing murmur,
heard at the apex during systole. All we can positively say of such
hearts is that they are really weakened by disease — that they have lost
their contractile power. Such hearts may have been primarily weak
organs, and just as they might not have been able to react properly to
any undue or excessive strain during health without showing the bad
effects of it, so during an attack of acute febrile disease they give way
rapidly both in function and structure.

Of course, to the pure anatomist or pathologist, who regards only
organic lesion as shown by eye and microscopical lens, to speak of func-
tional adynamia as something all important smacks too closely of mere
vague theory without proper and sufficient basis for intelligent argu-
ment ; but to others, and among these I find myself, there is just as
much cogency in the reasoning which admits a latent force or energy —
a vitality, in other words, which exists to a greater or less degree in
certain tissues of individuals and which is very defective in others — as
to attribute all symptoms and signs to appreciable local changes.

In any event, and for the while, we must count with such reasoning
and such facts ; and it is not the evidence of highest wisdom, to my mind
to ignore them. We are prone to explain these facts occasionally when
our every effort at accurate research, both as regards the tissues and
fluids of the economy, remains negative, by speaking of being run down,
under par, of poor nutrition, and using such catch terms as though
these words or expressions advanced our knowledge very materially or
were satisfactory in any final discussion.

In the malade imaginaire of Moliere there is a conference of the learned
doctors as to how and why opium causes sleep. The final conclusion
reached was "opium a le pouvoir dormitif" and that is all there is to it.

All saving agents, so to speak, whether regarded as food or medicines,
seem to me rationally what we should most keenly look for when called
upon to treat these cases. This is why agents such as tea, coffee, cocoa,
kola, etc., are so valuable when the body is submitted to a great strain
and where little or no other food or drink can be had. Take the sol-
diers of our army, the sailors of our navy, in time of war, on forced
marches or imprisoned in fortresses ; take men on the plains, or ex-
plorers iu the Arctic regions, or mountaineers who make high and
laborious ascensions — in any and all of these situations the universal
report is that in time of greatest need nothing will or can replace them.
Not only do they seemingly give almost as much if not more, at times,
of temporary energy and strength than alcohols or ethers, but their
power is far more enduring and beneficial when exposure or hardship
has to be for a long time resisted.

Physiologically they lessen the rapidity and degree of combustion in
the economy, the tissues are thus saved from any destructive action of


phagocytic cells, and living force and energy are thus spared to their

I have attempted in giving black coffee frequently to my cases of
acute febrile disease, with evidences of heart weakness or cardiac degen-
eration, to meet the most evident indications up to the present time. I
have supplemented or varied the use of coffee at times both with cocoa
and kola. The former of these, particularly in the form of extract,
given by mouth or hypodermatically, has often helped me when I had
almost given up hope. I am inclined to believe that if my faith and
trust were greater, and I were to use these agents sooner and more freely,
I would get far better results in cases of acute myocardial degenera-
tion. One reason I believe that these agents do not always respond to
our hopes is because the preparation employed is relatively inert. Many
cocoa leaves, as many digitalis leaves, are dry and inert and of poor
quality when first gathered. I cannot place too much insistence upon
this. I have experimented with many preparations of cocoa as sold by
different druggists, and many are relatively inactive and worthless.
Too much care and inquiry cannot be taken in order to obtain a thor-
oughly reliable drug. And it is only too true that the power the best
of us have over the march, duration, and ultimate outcome of acute
disease is limited, and that this small power is reduced to a minimum
when we employ drugs which have little or no physiological action
when employed in the doses and forms which are wide-spread.

Hence, in part, the great skepticism so visible everywhere among our
best clinicians and practitioners of widest experience when they speak
of the curative action of drugs. There are, I freely admit, few truly
valuable ones among the vast mass of those that are advertised and sold,
and for this reason, also, it behooves us jealously to guard and protect
those that are from the meddling of ignorant, fraudulent persons.

In many cases of acute myocarditis the question arises as to whether
we have to do with concomitant endocarditis or pericarditis. In some
cases, indeed, it is undetermined for a time at least as to whether the
symptoms and signs present are not entirely due to the inflammation
of the endocardium or pericardium and the myocardium is little or
not at all involved in inflammatory or degenerative changes.

Endocarditis is not easily diagnosed at times ; it may be very
obscure. The local symptoms are often almost or entirely absent, with
the exception of the systolic murmur present over a limited or some-
what wide area of the prsecordia. There may be no localized pain or
marked discomfort ; no increased pulse or force in cardiac beats; no
irregularity or intermittency of cardiac contractions ; no abnormal pul-
sation in intercostal spaces ; no vascular distention in vessels of the
neck. The local expression of endocardial inflammation in slight de-
gree simply reduces itself to the murmur. It is true this murmur may


be rougher, more intense, more metallic than the one proceeding from
mere dilatation of orifice without local change or from lack of close
coaptation of the velse due to lack of power in the heart muscle ; but,
as we know, the nature and intensity of a bruit is not of itself absolutely-
characteristic of inflammatory or other changes. Again, and this is
more frequently true, the murmur itself is absolutely similar to one that
we may fairly attribute to myocarditis alone. The pulse, of course, in
endocarditis may rapidly gain appreciably in force and frequency, but
this is usually true only when the inflammation of the endocardium is
considerable. There may be a sudden or rapid rise of temperature ; but
here, again, this means marked inflammatory changes of the endocar-
dium, and if accompanied by rigors or repeated chilly sensations there
will arise a reasonable suspicion as to whether there is not some septic
process present, such, indeed, as would lead to the ulcerative form of
endocarditis. If this be true usually the murmur has shown itself
rapidly and with much intensity, and its loudness very soon increases,
beside being accompanied with general phenomena quite different from
those of myocarditis, with tendency to cardiac weakness or failure.

I admit that much of the differential diagnosis is based upon proba-
bilities rather than upon certainties ; but this statement is no truer and
need be no more emphatic than in numerous other difficult positions in
the practice of medicine. Of course, the presence of a special form of
disease must always be considered. Other conditions being the same
I should look for endocarditis as being far more probable in acute
rheumatism than the other diseases already mentioned, simply because
we know that acute rheumatism has a particular predilection to attack
the endocardium. Even in rheumatic fever, however, I am now con-
vinced that we have rather exaggerated this tendency at times, and that
many instances of what is commonly affirmed to be endocarditis have
been without doubt mainly a myocardial inflammation or degeneration.

While I have not always been able to make the differential diagnosis
in the initial stage of the manifest cardiac determination, the march
of the disease and the nature and perhaps rapid or sure, though slower,
disappearance of the cardiac abnormal bruit have thoroughly convinced
me of the physical cause producing it.

If there be a pericardial inflammation the superficial character and
the nature of the friction-sounds may be sufficient to differentiate these
cases. Moreover, very soon the increased and special form of cardiac
dulness, the particular displacement of the apex-beat, the distant and
more muffled and duller apex- beats, with very possibly the almost entire
absence of these beats to inspection, and it may be palpation, help the
accuracy of our differential diagnosis very much.

I have not had occasion to see hearts at the autopsy table in cases of
influenza except where this disease had been complicated with pneu-


monia, and then the hearts resemble somewhat those already described.
One marked difference, however, is in the contents of the cavities. In-
stead of the right ventricle and auricle and large vessels containing
fibrinous coagula, these were much softer, contained far less fibrin, and
were darker and far more cruoric, viz., contained a far larger number
of red blood-globules. I am quite confident, however, that the heart
of very many influenza patients is much affected. I have no doubt
that the nervous structures, ganglia, vagi, and sympathetic have lost
their tone and gone through certain changes. They may be recognizable
under the microscope on account of the cardiac and other symptoms
present during life.

Beside the nervous involvement there is also abundant evidence in
influenza that the muscle is attacked, and it is highly probable that the
great depression, continued weakness, syncopal attacks, slow recovery,
frequent returns of some of these symptoms subsequently and somewhat
periodically at times, are all due in part to myocardial changes. In no
disease with which I have a clinical experience is it more important to
guard patients against overexertion than influenza during its acute
and subsequent stages.

Patients who have been attacked severely with this disease may show
after a few weeks or months some cardiac enlargement due to dilatation
and evidently occasioned directly by the influenza attack. Not only,
therefore, during the period of the acute stage of this disease should we
be specially careful in not permitting any physical exertion — not even
the mere sitting posture in bed without assistance and support — but
we should for many weeks subsequent to an attack at all severe urge
upon patient and friends the absolute necessity of great prudence and
the strict avoidance of all intemperate or continuous bodily or mental
effort. Many hours of the twenty-four had better be passed in repose
or sleep and complete quiet mentally, and the recumbent posture
should be sought whenever the heart shows any signs of exhaustion.
Going up stairs, walking too rapidly, lifting heavy burdens, indulgence
at the table, use of tea, coffee, or tobacco, should all be strictly limited
for many weeks or months. Of course, there is the personal equation
here, as everywhere in medicine, and there are many patients who re-
cuperate rapidly even from an attack of influenza, and who on that
account need not, perhaps, exercise quite the same severe precautionary
measures as others. It is also true that the poison may be far less
virulent in certain instances than in others, and, therefore, we should
not expect the same severe effects to proceed from it. Nevertheless, it
is ever a safe rule to bear in mind how essential it is for the patient's
ultimate well-being to be careful in the convalescent period of in-
fluenza, typhoid fever, rheumatism, diphtheria, the eruptive fevers, and


I have seen many times in the convalescent stage of these diseases
the pulse remain unduly frequent for long periods of time, and I have
likewise seen this tachycardia show itself after very slight exertion,
when the patient otherwise seemed well and could scarcely be made to
appreciate the importance of considering this symptom, which pointed
clearly to weakness of the muscular walls of the heart.

Bradycardia may also be present, and the marked slowness of the
pulse, going down frequently to fifty pulsations or less, may be the
most important if not almost the sole evidence of impairment of cardiac
power. Surely too much emphasis cannot be placed on the judicious
valuation of this condition. If it be properly considered and wisely
treated not only will convalescence be in the end much shortened, but
all danger of subsequent probability of cardiac dilatation will be avoided
as far as may be.

It is manifest that in cases of moderate endocarditis or pericarditis,
during their acute stage especially, it is incumbent upon us to insist
upon absolute rest in bed in the recumbent posture (and even though
the type of dise'ase in which it occurs may be very mild in char-
acter) for many days or even weeks ; and yet, after all, I do not believe
the danger from overexertion in these affections is half so great when
they are unaccompanied with myocardial changes, nor do I believe
that, per se, they are so threatening to the future well-being of the

I do not deny that the facts to which I have referred are more or
less well known to the average good clinician and wise practitioner ;
still, I know in my own case it has taken many long years of practical
observation and experience, and the care of numerous patients, to thor-
oughly convince me of its very great interest and importance. Here is
where, unfortunately, the modern text-book of practice falls far short of
actual needs. Sayings similar in import to mine may be alluded to in
a line or two, but that is about all, and unless a man's own thought and
daily experience and observation serve to bring the facts constantly
before him he is prone to ignore or forget them. Even modern text-
books on cardiac disorders are apt to be far too brief, in my judgment,
in treating of the importance of rest in the treatment of acute disease.

Most people will swallow drugs, cover themselves with lotions and
liniments, be blistered or burnt, even go through a minor surgical oper-
ation, with far more equanimity and resignation than they will submit
to being put to bed and remain there for days or weeks unless they are

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Online LibraryBeverley RobinsonEssays on clinical medicine → online text (page 11 of 20)