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in great pain or are suffering from some marked disablement that they
can thoroughly appreciate. The practitioner has a difficult role many
times, especially during the convalescent period, in managing these
patients to their own advantage.

It is not always wisdom to explain to people about their ailments.



ACUTE MYOCARDITIS. 101

They try to understand the doctor's position, and yet they do not.
They either exaggerate the gravity of their own case or ignore it far
too much. Whenever it is a question particularly of the heart, infinitely
more harm is sometimes done by showing accurately by explanation in
what the danger consists than in part to avoid explanation, or not to
speak at all, except to avoid making any categorical statement. This is,
of course, deplorable for many reasons. Truth is mighty and should
prevail, and an intelligent man or woman should claim the right to know
precisely what the matter is and what the physician really thinks of
their case. Just as soon, however, as the bald statement is made that
the heart structure is at all affected, then they proceed by vain im-
aginings to make themselves miserable for a long, long while to come.
It becomes almost impossible at times to disabuse their minds and make
life tolerable to them. They fret and worry, become introspective and
hypochondriacal, and lose snap and energy, which render their lives a
burden to themselves as well as to others. They are often the victims
of false dreads and foolish fears ; they imagine they cannot recover
and must always be, to a certain extent, invalids ; they harp on their
hearts, and they run from one physician to another to obtain expert
judgment. It would seem as though the minds of such could be dis-
abused, and that the earnest, convinced statement of their physician
that they would get all right in time if they are only careful and sen-
sible would be sufficient to quiet their fears and restore healthy mental
fibre ; but, alas ! in many cases this unhappily is not true.

I do not wish to be understood as upholding at all that this should
make the practitioner either untruthful or misleading, but I do mean
to say that it should make him very, very careful and circumspect as
to what he says. He must wholly gauge the disease he has to treat ;
he must, also, always consider the personality he has to do with ; and
singular it is that the very persons whom we might suppose are those
least likely to be demoralized by the truth if spoken fully and without
prevarication are, perhaps of all others, the ones to become most readily
discouraged and ultimately the most miserable unless with much
time, tact, and care they are absolutely convinced of the error in their
thoughts.

With respect to the other treatment of endocarditis or pericarditis, if
they be present, I would add that while I believe counter-irritation in
the form of iodine or blisters very useful frequently in shortening their
duration and intensity, I am not convinced that they would have much
value in the treatment of independent myocarditis of the sort I have
endeavored to study.

As to warm applications over the prsecordia, and, better still, hot
fomentations frequently repeated, and particularly where there is evident
cardiac weakness, these I believe are of really great value. They cer-



102 ACUTE MYOCARDITIS.

tainly stimulate cardiac contractions to a very notable degree, and even
though there be considerable increase already in bodily temperature, I
recognize no strong objection to their use.

To my mind, the question of the amount of fever is often of secondary
importance, and in nearly all cases is but one of numerous symptoms
pointing to the intensity or gravity of the systemic poisoning. To com-
bat it rationally and without manifest detriment to other expressions of
disease may be all right, indeed probably is correct according to our
actual knowledge. To do more than this is many times obviously
uncalled for, and tends very much to produce harmful interference.

If the condition be already an adynamic one, where the bodily forces
are at a very low ebb and other forms of immediate and powerful
stimulation are required, I fail to see why transmitted heat, properly
applied, may not awaken and indeed partially restore wasted nerve force
very much more certainly than cold. To cite particular instances in
which this is true, even though not wholly analogous, would not be
difficult.

In any great shock to the nervous system following a blow or fall ; in
the complete nervous depression from loss of blood ; in the nervous
exhaustion caused by fright or imminent peril ; in the utter goneness
accompanying bodily privations due to lack of food or sleep, heat
locally applied over the heart, either as hot-water bag, hot compresses,
mustard poultices (where it is combined with the counter-irritant),
would be our first thought and usually prove most helpful ; and as the
body heat of an infective disease is in many particulars nothing very
different from the other appreciable expressions of lowered nerve tone,
why not make use of it promptly and efficiently ? ■

As to the general treatment of endocarditis and pericarditis, I would
naturally incline to the use of the salicylates in moderate doses if acute
rheumatism were present ; but I should be more than doubtful of their
utility even in these instances where there were complications of the
other febrile conditions studied in this article. Certainly, I would not
give them where the nutrition was already at a low ebb or the stomach
had shown signs of intolerance.

During the convalescent period of acute myocarditis complicating
acute febrile diseases the indications for massage, resistant movements,
and saline carbonic baths, according to the Schott system employed
originally at Nauheim, seem pretty clearly defined.

It is to be borne in mind, however, that just as dyspnoea is often a
very marked symptom of myocarditis in its most acute stage, so later it
will frequently guide and direct us as to the efficacy of the move-
ments and baths and the duration of them. On its appearance in any
notable degree they should be stopped and only resumed with great
care and moderation. Harm results more frequently from doing too



ACUTE MYOCARDITIS. 103

much at too early a period than through a judicious reserve as to both
of these considerations.

It is true that the Nauheim treatment employed at the spring?, or
artifically used elsewhere, may prove to be very beneficial in well-
selected cases, even though the heart fibres be degenerated. It is,
also, unquestionable that where the degeneration is far advanced and
the general nutrition has become much undermined by previous disease
or advancing years, it may work more than passing harm and become
of very little real value, but rather detrimental than the reverse.

Acute myocarditis may and does occur frequently among children
as a complication of their acute febrile diseases, and especially is
this to be remembered in scarlatina, whooping-cough, diphtheria, and
measles.

I am confident that this acute degeneration of heart muscle will
many times explain sudden failure of cardiac power when apparently
the patient is progressing favorably. I am also convinced that it
will explain the delayed convalescence of numerous cases in which this
complication would easily be disregarded or overlooked unless partic-
ular attention be directed to it. No doubt many instances of subse-
quent cardiac dilatation, with or without accompanying hypertrophy,
have been occasioned solely by inattention to or ignorance of this
muscular degeneration.

The very activity of children, their desire to play and romp and tire
themselves with their games and contests, is an additional reason why
special care should be exercised so as to ward off an unfortunate sequela
which may be otherwise lasting and troublesome. I have not infre-
quently met with cases which, as I interpret them at present, may trace
their later cardiac inadequacy to the influence of diseases of early
childhood.

I do not believe, in my experience, that the acute myocarditis of chil-
dren differs very materially, so far as symptoms go, from the same dis-
ease in adults. The ultimate prognosis, however, it seems to me, is less
serious, simply because the nutrition of the child being usually more
active his cell elements are re-established sooner and more surely, and
hence the untoward, far-reaching effects of cardiac weakness are less
likely to become manifest.



CHRONIC MYOCARDITIS AND FATTY DEGENERA-
TION OF THE HEART.



OLiNicALLy these two expressions of cardiac degeneration are fre-
quently most difficult to differentiate accurately. We have our sus-
picions based upon a fair interpretation of the case as a whole, and
sometimes the results of the autopsy justify our probable diagnosis.
Many times we believe we shall find not merely fibroid changes or,
indeed, simple fatty degeneration, but there will be a combination of
both changes. In the advanced forms of fatty change particularly,
and whenever we have in the history of the patient efficient causation
of such alteration, our belief in its existence is very positive. There
are, however, numerous instances in which our diagnosis during life is
at best very problematical, and yet it seems to me any other diagnosis
at what we observe falls short of seeming truth, and is at best somewhat
unsatisfactory to the practitioner. While we know, for example, in
the graver forms of ansemia, and notably in the so-called pernicious
form, fatty degeneration of heart muscle is no uncommon finding, I do
not believe that physicians are apt to consider that the heart may be
structurally affected in the simpler forms.

It is true that many symptoms point to cardiac weakness. Notably
we would put emphasis on lowness of the heart sounds at times, on
extreme rapidity of its beats, with sensations of fluttering and cardiac
distress. Sometimes there is a systolic murmur which covers in part
or wholly the normal sound. Frequently this is absent. Attacks of
dizziness or faintness may come on readily and repeat themselves with
little or no sufficient cause. I have seen such an attack where the
patient was unconscious for a period of half an hour or more. During
this period the pulse was very faint, sometimes almost imperceptible at
the wrist. There was occasionally a lapse of pulsations at the wrist
for one or two cardiac beats, accompanied with marked irregularity.
The extremities were cold, the respiration shallow and suspicious.
After such attacks and when the patient's strength had partially
returned there was no enlargement of the heart which could be discov-
ered, no abnormal pulsations either on the chest or in the neck, and
no venous hum in the jugulars.



CHRONIC MYOCARDITIS. 105

I am of the opinion to-day that such cases often mean heginning
cardiac degeneration of the fatty type, and that any other interpreta-
tion inadequately expresses the best medical judgment. Of course, they
require iron and arsenic to re-establish the blood condition. They are
also temporarily benefited at times by the use of intestinal antiseptics;
still, in order to bridge over the acute attacks we must give cardiac
stimulants freely and repeatedly and aid with the heart tonics of
strophanthus and strychnine judiciously administered. Oxygen also
given systematically is of great help and must be insisted upon.

We all feel we know the usual gouty heart fairly well, viz., the heart
affected with moderate hypertrophy of the left ventricle and adjoined
to evidences of more or less fibroid changes in the kidney and general
arterio-capillary circulation. Whenever this hypertrophy is no longer
thoroughly compensatory and evidences of heart weakness develop, as
shown by local and general signs and symptoms, we are frequently
brought to the position of asking ourselves whether cardiac degenera-
tion be present, and if so, its extent, variety, and nature.

Our diagnosis must be determined by several considerations inde-
pendently, perhaps of the underlying and evident gouty changes. It
may be that the patient has been a free liver, is of corpulent frame, and
has indulged more or less and for a considerable time in the use of
alcoholic stimulants.

These conditions would tend to make us reasonably sure of the
presence of some fatty degeneration of muscular fibre. The condition
also of the liver, notably where it is torpid and enlarged and there is
possibly some additional abdominal enlargement with tension of the
parietes, would make us suspect cirrhotic and fatty changes in this
organ. The presence of ascites may remain doubtful for weeks and
months, and never, indeed, be accurately determined. Again, in a
relatively short period succussion and palpation may unquestionably
reveal abdominal effusion in small or moderate quantity. In these
instances the pulse may never have increased tension, or only to such
slight degree that our tactile sensations, or even the use of the sphyg-
mograph, may not corroborate our suspicions, but simply leave us in
reasonable doubt. Here, again, it is the skilful touch, the keen appre-
ciation of local changes which proceeds from long, careful experience,
or the expert and, may be, repeated use of the sphygmograph which
shall solve our difficulty. In any event, but particularly where our
findings are positive, we believe that we shall detect an excess of fibroid
tissue in the heart in certain spots between atrophied, compressed, or
degenerated fibres.

The cerebral symptoms, which may be passing or more or less per-
manent, while pointing to cardiac degeneration, do not tell us positively
whether the fibroid changes or fatty ones are predominant. If the



106 CHRONIC MYOCARDITIS.

mental activity of the patient has failed slowly and evidently for many
months, if the memory be impaired, somnolence increasing, and even
slight mental exertion be accompanied by geeat fatigue, slowness, and
difficulty of speech and obvious lethargy, we are inclined to the opinion
of marked fatty degeneration, always supposing the other signs and
symptoms mentioned are present. If now the arterial tension remains
high the coats are visibly thickened, knotty, tortuous, giving proof of
decided atheromatous changes, we are prone to believe that the intra-
cardiac condition will be more likely that of chronic myocarditis,
with marked fibroid changes. Any calcification of the arteries, as
of the radial or temporal, will only accentuate and confirm this judg-
ment.

This condition we should not find except in very rare instances,,
unless the patient were one already of advanced years or the gouty
dyscrasia were intense and of hereditary origin increased by bad habits
of life, speaking mainly from the hygienic stand-point.

In some instances we are led to believe that on autopsy we should
find the coronary arteries notably affected. These examples are espe-
cially those in which prsecordial pain and anxiety had been evident at
times and with moderate or great intensity.

I saw a patient, not long ago, a professional man, about fifty-five
years old, who gave the following history : He had been a careful
liver so far as food and alcohol were concerned, but had for many
years smoked immoderately and kept late and irregular hours. He had
done much hard work in active professional life and in a literary way.
He had for many years been a chronic dyspeptic, showing itself by
slowness and impairment of digestion, belchiDg of wind, and capricious
appetite. He had never suffered from symptoms of heart weakness or
distress. Calling to see him, I found him pacing the floor, with marked
dyspnoea, prsecordial distress and great mental anxiety, and the feeling
of impending disaster. The hands were cold and the face blanched ;
the pulse was regular and tolerably full ; the radial arteries were thick-
ened and there was apparently increased tension ; the heart was en-
larged, showing hypertrophous dilatation, moderate in amount. This
attack had lasted twelve hours, without relief spontaneously, and was
increasing in intensity, as shown by the augmented distress. The
swallowing of numerous soda-mint tablets, which frequently gave relief
to simple dyspeptic conditions, were of no avail.

I prescribed immediately a heart tablet of strophantus, digitalis,
atropine, and nitroglycerin, and in a few hours there was great relief.
The urine during the attack was high-colored and concentrated, but
contained neither albumin nor sugar. In a few days he was about as
usual. I advised repose from work and careful dietary, with the use
of cardiac stimulation if required. In a short while he was better than
he had been in many months and had had no recurrence of his angi-
nose symptoms.

No doubt, to my mind, this patient has intracardiac changes, probably
of the fibroid type. It is probable also that this coronary circulation is



CHRONIC MYOCARDITIS. 107

defective and that endarteritis is present. Did he have some temporary
and incomplete obstruction of one or other of these arterial branches at
the time of his attack? This, I believe, although I cannot affirm it. I
only know that the other diagnosis is sufficient to explain his symptoms
satisfactorily. Probably the causes enumerated were all more or less
contributory to the development of the attack. Judging by the
sequence of events, I believe that nervous tone to the heart was
partially restored by relative rest from work and that the stomachal
condition was improved by appropriate dietary. The use of the cardiac
tablets during the attack certainly gave marked relief and possibly
prevented a fatal termination due to complete clogging of one or both
main arterial coronary branches.

I have known of the case of another professional man, about fifty
years of age, whose habits were not different from those of many toler-
ably successful ones at this period residing in a large city. He worked
moderately but not unduly ; he ate and drank with proper selection
and due regard for his habits and peculiarities ; he gave himself a fair
amount of recreation, took long summer vacations, and was fond of the
water and yachting. At times he had very slight attacks of dyspnoea
and praecordial anxiety, which never meant absolute pain or great dis-
tress ; indeed, these mild attacks occurred at infrequent intervals and
disappeared spontaneously and in a few minutes or hours at most. One
afternoon, hastening home from his boat on the river to dine and meet
his wife, who was anxiously awaiting him, as he was late, he had an
attack of severe angina pectoris and died suddenly in the street.

The following description of the cardiac changes found at the autopsy
is copied textually from notes kindly given me by the pathologist :

Moderate degree of hypertrophy of left ventricle. Valves compe-
tent. Atheroma in mitral valve and in beginning of aorta. In latter
situation this is most abundant about origin of coronary arteries, whose
lumen is distinctly encroached upon by it. On opening of coronary
arteries atheroma is found in their walls extensively beyond their origin.
In this way their calibre is considerably narrowed. Microscopical
examination of heart muscle reveals increase in pigment in cells about
nuclei and a slightly granular condition of muscle cells generally, but
no distinct fat. There is no obscuration of transverse strise, and there
is no increase in fibrous tissue. 1

Analogous instances to this are not infrequently met with. Of
course, the precise nature and the degree or intensity of the signs and
symptoms experienced during life vary greatly. In a similar manner
the rapidity or suddenness of the fatal termination, if it occur, varies
also very much. Whenever the coronary circulation is immediately and
wholly obstructed sudden death takes place and one of several findings

1 The findings at autopsy are here unusual, in that there was no occluding thrombus and
the muscle changes are slight.



108 CHRONIC MYOCARDITIS.

is evident at the autopsy. It may be that the coronary artery is filled
up with an embolic plug, which has its origin in the heart either from a
cardiac thrombus or from a detached portion of vegetation from a dis-
eased valve or cusp of the mitral or aorta. In such cases the coronary
arteries may be relatively free of disease, although frequently there
may be even here a concomitant condition showing local degeneration,
though slight in amount. Wherever — and this occurrence is much
more usual — the coronary arteries themselves are more diseased, show-
ing inflammation, thickening — endarteritis, in other words — or pro-
nounced atheroma, with possible calcification at certain points, they
are occlued with a thrombus.

The arteries may be occasionally affected and narrowed mainly or
entirly at their orifices, or what is truer, ordinarily, the coronary
arteries are thickened, tortuous, atheromatous, or calcified throughout
the larger portion of their distribution. These changes have, of
course, greatly decreased their lumen or the extent of their calibre
internally, so that the heart has been imperfectly nourished by an
insufficient blood supply for a long period, and at a given moment a
thrombus forms locally and almost inevitably, and a fatal result ensues,
although, of course, in a somewhat less rapid manner than if an em-
bolus has been the immediate and efficient cause of death.

The local changes of the heart muscle in these latter cases particu-
larly partake of a fatty or fibroid character and are more or less local-
ized or disseminated in their distribution, according to modifying gen-
eral conditions. Moreover, the time during which the changes have
taken place and the age of the patient have much to do with the
character of these changes. As I have already pointed out, it is
almost impossible prior to death and direct examination of the heart
to state positively just what shall be found, so far as the precise changes
or the limitations of the morbid involvement of the coronary arteries
and heart muscle are concerned.

In old valvular troubles of the heart, whether they be of the nature
of stenosis or regurgitation, in chronic pericarditis where the adhesions
are tough and fibrous, in an advanced condition of hypertrophy of the
heart, with probably much cardiac dilatation, fatty degeneration is
almost surely going to occur at a given time, provided the patient's
life is sufficiently prolonged; then, of course, notable cardiac weak-
ness, prsecordial distress and dyspnoea, cyanosis, infiltration of the lower
limbs, weak, unequal and irregular pulse, deficient and concentrated
urinary secretion, are some of the numerous painful phenomena with
which we are all familiar.

In these cases we naturally expect and usually find post-mortem far
more disseminated degenerative changes of the heart muscle than we
do in the instances previously cited. As a rule, the left ventricle, and



CHRONIC MYOCARDITIS. 109

more particularly the portion of it near the septum, is specially affected.
The columns carnese — the papillary muscles — are frequently reduced
in size, changed in color, soft to the touch, possibly giving a greasy
feel, easily torn or lacerated, and showing to the naked eye indubitable
evidences of fatty degeneration which microscopical investigation will
merely serve to reaffirm.

The right ventricle may also be degenerated in parts, although less
frequently, and it is now known that the auricles are sometimes in a
certain degree degenerated, although this statement was formerly
denied.

If there be chronic myocarditis present, which occasionally occurs,
the heart muscle is hard and resistant in spots and very often dimin-
ished in thickness where this exists, owing to the deposit of fibrous
tissue which has practically caused many muscular fibres to atrophy,
degenerate, or almost or completely to disappear.

In those corpulent people who have accumulated flesh continuously,
slowly, and in large amount, the heart is no exception to the great
number of viscera which become more or less involved. The deposit
of fat upon and around the heart usually seeks at first those regions
where fat is deposited to some extent normally, and particularly in the
grooves between the auricles and ventricles and along and over the
intraventricular septum. Later, it is no uncommon finding to discover
fat under the epicardium or the endocardium. Whenever this occurs
the fatty infiltration has extended deeply into the heart muscle and
between the muscular fibres to such an extent that the force of the
heart-beats is notably lessened, and many of the phenomena which


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