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characterize true fatty degeneration of the cardiac muscle are present
during life. Not a very long time passes under these circumstances,
unless treatment is effective in checking accumulation of fat in the
tissues, until the fat deposited penetrates the muscular fibres themselves
and produces true fatty degeneration of the heart.

These obese persons are, therefore, always a source of special solici-
tude to us when we take care of them in any of their ills. All acute
diseases in their instance are of moment, and what would be a relatively
simple affair with a thin person or one with only moderate or healthful
embonpoint is apt to take on a certain degree of gravity. A slight
bronchitis, an attack of influenza, a mild rheumatic seizure or a limited
attack of acute pleurisy will almost invariably lessen their bodily
strength very rapidly, and soon their respirations are much quickened,
their pulse becomes rapid and weak, and their cardiac action so feeble
as to require immediate and frequent stimulation. The only way to
treat such patients safely is to suppress all bodily exertion as much
as possible for a time and to lessen, if feasible, their mental cares and
anxieties. Even without any marked febrile movement they should



110 CHRONIC MYOCARDITIS.

be put to bed and kept there until the acute attack, whatever it be,
has completely passed, during several days at least. Of course, if
there be marked febrile reaction the urgency and necessity of this
action on the part of the attending physician is even far more impera-
tive ; and here it is well to remark that in such cases, as frequently the
rise of temperature is often only slight or moderate, the patient's imme-
diate and nearest relatives are not at all alarmed, and not infrequently
consider the wise and careful, conscientious physician a great alarmist
when he is merely obeying his best judgment if he insists absolutely
upon the importance of following out strictly his orders.

At first, in some of these cases, and leaving out attacks of acute
trouble for the while, the careful examination of the heart physically
will not permit us to affirm that there is any notable cardiac enlarge-
ment ; and even the heart sounds, when the patient is in his usual
health and free from physical exertion and not harassed with business
or other cares, will not show any special weakness, irregularity, or
notable murmurs ; but often very slight exertion — as going up stairs,
climbing a hill, hastening, even an ordinary walk on level ground —
causes distress, and they will be in a panting condition almost imme-
diately, become dizzy and faint, and the face 'is suffused with an undue
pallor, or else their cheeks and eyes are congested and their lips are
blue and cyanosed. These cases we all see, we meet them every day
— and often, I am sorry to say, do not guide and direct them intelli-
gently.

If the person affected with obesity is young I do not believe, as a
rule, that the immediate outlook of the case from a cardiac stand-point
has usually much gravity ; and yet even then we must not ignore the
possible outcome and the danger of dilatation of the heart resulting —
more or less lasting and important — unless we insist upon proper
dietary, exercises, and judicious medication. But in women, near the
climacteric especially, and in men near or past middle life, we cannot be
too formal about our protests to be careful and heed judicious medical
counsels ; otherwise we shall have soon to deplore an evident cardiac
enlargement and dilatation, which from a prognostic stand-point is cer-
tainly very grave, as the underlying cause is often fatty degeneration
of cardiac muscular fibre, and in view of the age and condition of the
patient is very difficult, not to say impossible, to remove.

In young girls, particularly, obesity is apt to follow acute disease like
scarlet fever or typhoid and to be allied with chlorosis. This ansemia
is sometimes corrected by proper treatment without too great lapse of
time; again, it is most persistent and resists all our efforts for months
and years. During this period such girls are liable to syncopal attacks
and other symptoms which surely indicate pronounced cardiac weak-
ness and cause much distress and anxiety to all concerned — patient,



CHRONIC MYOCARDITIS. Ill

relatives, and physicians. In older patients the blood may be of rela-
tively good quality and not seemingly add to the distressing or merely
uncomfortable symptoms.

In some women who have profuse menstruation ; in those who are
married and have had several children ; in women at the time of the
menopause — the amount of blood often lost at the monthly flow is
excessive, and the result is that the bodily strength is greatly diminished
and the blood examination shows great diminution in haemoglobin and
the number and appearance of the red cells.

Here, again, I have no doubt that the anaemia thus produced hastens
considerably fatty degeneration of heart muscle and the subsequent
development of cardiac dilatation. In these instances, if for some
reason the patient is obliged to submit to an operation and take an
anaesthetic, of course the attending physician, surgeon, and, above all,
the giver of ether or chloroform or even nitrous oxide should be par-
ticularly careful. In uterine fibroids which require operation I would
urge more than ordinary solicitude in administering anaesthetics, and
especially in corpulent women about middle age. These women are
affected with several conditions which are apt to produce fatty degen-
eration of the heart. It may be that prior to the operation the heart
had been thoroughly examined and was declared competent and prob-
ably free from more than a considerable degree of fatty infiltration,
making part, as it were, of the increased fatty accumulation in the
body not only in the cellular tissue under the skin, but also of several
of the other viscera. During the course of the anaesthesia, however,
and subsequent also to the operation, general phenomena of cardiac
weakness showed themselves, which, without doubt, at times hastened
or, indeed, ended the fatal ending of the case.

Whether under these circumstances, as in one unfortunate case I
have in mind, the cardiac failure would at all explain the rise of tem-
perature and local evidences of peritonitis which developed, or whether
these latter phenomena were merely due to some imperfection in the
operative technique, or, indeed, to penetration and absorption of septic
material in the abdominal cavity, I am not wholly convinced. What
we do know is this, viz., when a sudden and great loss of blood occurs,
accompanying the severe shock to the nervous system, and indeed the
whole organism, inseparable often from the results of a very severe
operation, conditions arise which may readily serve to explain increased
temperature, paralysis of the bowels, local congestions of intense degree
leading rapidly to inflammation, the formation possibly of purulent
infiltration, and death.

Our overwrought theories of microbic infection, it appears to me,
make us partially blind to the broad notions of general pathological
physiology, which I am confident will outlive narrow and confined



112 CHRONIC MYOCARDITIS.

notions of the origin and development of disease, and so it may be in
the case referred to.

In no condition do we dread more the development of fatty degenera-
tion of the heart than in that of chronic alcoholism. In all acute dis-
eases, but particularly so in the pneumonia of adults, when we know
we have to do with a chronic alcoholic, our prognosis of the outcome of
the case should always be carefully guarded. No matter how mild the
attack may apparently be in the beginning — no matter how hopeful we
might be in other cases as to the future course of the disease — in view,
perhaps, of the small area of lung involvement and the mildness of the
general reaction present, danger is always lurking and may show itself
almost at any moment, either during the acute stage of the pneumonia
or in the early convalescent period, by sudden pulmonary congestion or
oedema, with accompanying heart-failure ; or, indeed, the heart itself
may rapidly or suddenly cease to beat, and the patient die in a syncopal
attack with dyspnoea and apparent asphyxia, or a convulsive seizure
resembling closely a so-called uremic attack. The slightest effort may
bring on such a result. Going to stool, raising himself, or turning
over in bed without the help of a nurse may be among several efficient
causes which bring about instant dissolution. Again, the fatal occur-
rence may come about without any accidental circumstances whatever
to which we would direct attention.

Not only in acute diseases are these statements true, but they are
almost equally true when the individual has apparently been in his usual
health. Thus it is we hear of many cases of sudden death attributed
to so-called heart-failure, which means nothing tangible or obvious, but
which should mean fatty cardiac degeneration. If an autopsy is made
it will frequently demonstrate the fact beyond reasonable doubt.

In certain autopsies carefully conducted, so far as visible appearances
are concerned, a report is occasionally returned that no sufficient cause
of death has been discovered. The heart is about of normal size,
there is no valvular disease, and the cardiac fibre does not seem notably
affected. There is assuredly no pallor of the heart muscle ; the heart
may not flatten out on the table and the muscle may not be easily torn
or lacerated ; indeed, the heart muscle is deeply stained or of more than
ordinary deep red coloration. In some instances this staining is due.
simply to the imbibition of the muscular fibres with the coloring-matter
of the blood due to changes caused in this fluid. While this appear-
ance is oftener present in acute febrile disease than it is where no such
intercurrent complication has taken place, yet the cardiac appearances
may be as I have described them in chronic alcoholics who have died
suddenly.

The microscopical examination of the cardiac fibres in these instances,
if made — and it always should be made — will not infrequently reveal



CHRONIC MYOCARDITIS. 113

manifest granular or fatty degeneration of muscular fibres, possibly
limited, but more usually disseminated. Whenever the changes are
limited we should be careful to examine the condition of the coronary
circulation, and frequently there will be found endarteritis or athero-
matous changes.

In the senile heart, especially among those persons who have led a
moderately careful and regular life, we are more inclined to diagnose
fibrous changes than fatty ones if the heart begins to show decided
weakness, irregularity, and intermittences. With this condition there
may be moderate enlargement — usually hypertrophous dilatation.
There may be no abnormal cardiac murmurs, and frequently the puke,
instead of being irregular and weak, may be of good tension and very
regular, showing trouble only by a little lack of fulness and undue
slowness. Of course, the arterial coats both at the radials and temporals
may be thickened, tortuous, and stand out prominently, owing to the
shallow layer of subcutaneous cellular tissue.

The urine in these cases may be in fairly good quantity, but is ordi-
narily of somewhat low specific gravity, without sugar or albumin. An
occasional granular or hyaline cast is often discovered. With a ten-
dency to constipation, which often exists, the quantity of urine elimi-
nated in twenty-four hours will sometimes be decidedly below normal.

With any little fatigue, with any slight error of diet, with any
prolonged exposure, with any excessive heat or cold, with any rapid
change of temperature even, these old people are apt to feel poorly.
They lose appetite, they sleep less well, their bronchial secretion is
increased so as to produce annoying cough for some days, they are
apt to become lethargic and inclined to doze frequently, and it is not
uncommon to have them complain of feeling dizzy or faint. All these
symptoms are unquestionably due in some instances at least to cer-
tain fibroid changes in the heart muscle. These changes are, how-
ever, not usually limited there ; they are more or less disseminated
everywhere in the arterio-capillary system, and several of the different
viscera are notably affected, and particularly is this true of the
kidneys, the liver, and the lungs. We have in these cases the best
expression, without doubt, of the general disease so ably described
originally by Gull and Sutton and so well added to by the labors of
George Johnson and other able writers.

As regards the effect of syphilis in producing cardiac degeneration,
either of the fibroid or fatty type, I have very little to say from the
point of view of my own personal observation and experience. In a
few rare instances, it is true, where the syphilitic poisoning was intense
and the constitutional effects had become wide-spread by reason also of
its duration, I have seen the internal organs evidently much affected.

Syphilitic gummata of the liver I have occasionally observed, and



114 CHRONIC MYOCARDITIS.

in connection therewith there have been fatty and fibroid changes.
Undoubtedly the same products may occur in the heart walls, although
very infrequently in the ordinary routine of general hospital or private
practice. Its possibility, however, should be kept in view, and where-
ever we have to do with those changes in deep-seated organs of syph-
ilitic origin which cleary show its special virulence we should pay
particular attention to the condition of the heart. If there be signs
and symptoms pointing clearly to cardiac weakness coming on slowly
and increasing constantly it is good clinical conduct to have our mind
alive to the possibility of an intracardiac gumma and to the fatty and
fibroid changes which may depend upon or result therefrom.

After what I have written, the prognosis and treatment of these
structural changes should be considered. In general it may be said
that if the process has come on with some rapidity, or if the cause be
possible of removal, the prognosis is far less grave, at least perspec-
tively, than if the contrary conditions are true. Of course, in the
fatty change of the heart, which I believe possibly or probably exists to
a certain degree at least in a few anaemic young women, this condition
is undoubtedly curable in a shorter or longer time by judicious methods
-of treatment. If the anaemic state should, on the contrary, become of
a more advanced or pernicious type, we all know that while we may
and do obtain temporary good effects, which for a while at least may
seem to promise a permanent cure, our hopes are apt to be in vain.

This is thus far the history of the medicinal effects of large and in-
creasing doses of arsenic and the use of intestinal antiseptics according
to the method of Hunter in the treatment of pernicious anaemia. The
able and exhaustive report of Cabot before the Association of American
Physicians, May, 1900, would serve only to confirm the correctness
and sadness of this view.

In all instances, of course, where the anaemic condition and the
accompanying cardiac degeneration, probably fatty, depends upon or
is occasioned by malignant, incurable disease, so recognized at the
present time, we cannot properly hope for any amelioration of the
cardiac changes. In most instances where the alcoholic habit has been
largely instrumental in bringing on signs and symptoms of cardiac
fatty degeneration and similar changes in other viscera — if these
changes are not too far advanced and if the alcoholic habit be entirely
suppressed — we may reasonably hope in many examples for a measur-
able degree of improvement in the physical condition of the patient and
possibly for a complete cure. This happy result can only be obtained
with considerable time, however, and by absolute attention to abstemi-
ous habits of life, and, above all, by complete abstention from alcohol
in future. Of course, if the alcoholic habit has been an excessive one
and long continued, and if the patient has already reached middle life



CHRONIC MYOCARDITIS. 116

or passed beyond it, the ultimate outlook of the case is far less hopeful.
In this matter, however, personal idiosyncrasy and constitutional ten-
dencies should always be considered and much weight given to their
due estimate.

I have known certain individuals to have a pronounced alcoholic
habit of many years' duration, and yet during a large portion of the
time they have shown no morbid symptoms or signs of special moment
resulting therefrom. When morbid phenomena develop finally in these
cases, pointing unerringly to involvement and degeneration of the
heart muscle, I still feel a reasonable hope that they may be able to
arrest their disease, provided always that I can persuade them to
restrain absolutely their alcoholic appetite.

In other cases so soon as the cardiac degeneration is clearly present
the onward march of the disease takes place apparently without halt
or hinderance. The march onward and downward may be slow or
rapid, but, unfortunately, it is sure, and our best remedial means are
ineffective to delay or arrest its course.

In certain obese persons, by a proper system of diet and exercise and
suitable cardiac tonics at times combined with the continuous and
judicious inhalation of oxygen during weeks and months, we may
sometimes obtain very good effects. The prolonged use of iodide of
potassium in these cases, given in moderate doses, always supposing it
is well borne by the stomach and eliminative organs (skin, lungs, and
kidneys), is in the judgment of many capable observers very useful
and takes the place oftentimes of nitroglycerin and the nitrites with
great advantage.

A few observations of individuals, young or past middle life, have
made me believe that the treatment of Nauheim in well-selected cases
and managed with discretion and good judgment and with a mental
eye, single and devoted to the best good of the patient, has been un-
questionably of great use for a time. The great risk of this spa treat-
ment, as of all others, resides in the fact that even intelligent, culti-
vated physicians, here as elsewhere, become in a sense the victims of
their own exaggerated enthusiasm, and when a patient comes under
their care they are apt to push their treatment inconsiderately perhaps,
and sometimes too far.

Again, it occurs — I have known such a case — an individual past the
meridian of life had been sent to Nauheim for treatment by his family
physician, and although the patient when he reached the springs was
in no condition to go through the spa treatment — or originally, even,
he was not a suitable case for treatment, either owing to his precon-
ceived notions or the stress he laid upon carrying out what he was
ordered from home to do — led the local practitioner of Nauheim to
permit the following up of what perhaps, if his better judgment had



116 CHRONIC MYOCARDITIS.

acted coolly and deliberately, he would not have permitted, or in
another case have only permitted in a very limited measure.

In some cases one treatment at Nauheim may be decidedly useful,
but unfortunately has not been completely successful in establishing a
cure. Such a patient is sometimes told to return another season, or
another, and better results may or will be obtained. This, unhappily,
is an error fruitful of bad consequences. The patient has really
obtained all the good possible from the saline carbonic acid baths and
the regulated resistant movements. It would have been far better for
these persons, in my judgment, if they had remained away from the
spa later and if they had sought from other means all the improve-
ment they could fairly hope for.

It is the wise, conscientious physician, who is thoroughly familiar
with the personality, habits, and surroundings when at home of these
patients, who should really guide and direct them. I say it most
regretfully that oftentimes his voice is like as one " crying in the
wilderness," and the wisdom of his forethought, wide knowledge, and
clear-sightedness is rarely or perhaps never fully recognized. In
senile changes of degenerative type affecting the heart, and especially
where interstitial fibroid changes occur, accompanied usually, as I have
already said, by more or less general changes throughout the whole
arterial system, a wise conservatism should always prevail. It is utter
foolishness to suppose that we can modify in any appreciable degree
what has very slowly and surely taken place, and what is, after all,
many times only the outward and visible expression of the progress
at times or the result of " anno domini," from which man no more
than other animals is exempt.

There is a natural growth and natural decay, and these fibroid
changes in the heart and vascular circulation are to be wisely regarded
as nature's showing in due season. In such cases, therefore, treat
symptoms as they arise with the hope of temporary relief and tem-
porary benefit many times, but no more hope to arrest or change the
inevitable permanently than to change the river permanently in its
course by an insignificant and temporary dam. In the fatty degeneration
which complicates chronic valvular cardiac conditions, which is either
the cause or the result of cardiac hypertrophy or dilatation, something
may still be done.

The general nutrition of these patients may be kept up by suitable
food, and their emunctories may be properly stimulated when required
by baths, diuretics, and general laxatives. Breathing pure air and gentle
exercise in walking will sometimes prove remedial. The blood should
be kept in good condition and tonics may be required. Heart stimu-
lants are often temporarily useful. In the event of evidence that the
condition is not progressing favorably, strychnine is advantageous



CHRONIC MYOCARDITIS. 117

when continued for some time, with occasional interruptions, in moder-
ate doses. Where there is much arterial tension, with marked dysp-
noea, iodide of potassium, if well borne, will give temporary relief and
occasionally proves permanently beneficial. All sudden or great efforts
should be most carefully avoided, and especially is this true in the
secondary great hypertrophy which follows aortic regurgitation, when-
ever the heart shows that its walls have become hopelessly degenerated.
In these instances it is that many sudden- deaths occur, as the records
of our hospitals abundantly show, as well as occasionally experience in
private practice.

In cases of suspected syphilitic degeneration affecting the cardiac
muscle, iodide of potassium, freely given, or the mixed treatment wisely
ordered according to circumstances, should be our main reliance.

In writing the foregoing paper I might have insisted more than I
have done upon the purely pathological aspects of my subject. I might,
indeed, have given a careful description of pathological findings in
these cases at the autopsy when it was made, and especially when made
with particular reference to the condition of the cardiac walls and the
coronary circulation. To have done so would have lengthened my
paper unduly, and would, moreover, have taken away perhaps part of
the interest attaching to it as a clinical study, upon which I would place
special emphasis.

Having said this by way of an explanation I would now crave
attention for a few words from the point of view of the gross and
minute lesions present in the cardiac muscles in different instances.
Wherever the heart is notably affected with fibroid changes the muscle
there becomes tougher and more resistant, besides showing thinning of
heart walls in places. In the spots thus affected there is a yellow-
whitish coloration, which indicates somewhat the probable nature of
the degeneration. The degeneration is prone to occur in patches and
especially in certain regions of the left ventricle and near the septum
and apex than elsewhere. Under the microscope the parts affected are
shown often to be almost wholly composed of fibrous tissue.

In other cases, while the fibrous tissue is in great excess between the
muscular fibres, the latter still are present but atrophied or degenerated
more or less. The nucleus has sometimes disappeared as well as the
strise, and there may be more or less pigmentary deposit in the form
of granules, regularly or irregularly distributed. Wherever the
nucleus of the muscle still exists the pigmentary granules are apt to
be present in larger numbers about it than elsewhere.


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