Beverley Robinson.

Essays on clinical medicine online

. (page 4 of 20)
Online LibraryBeverley RobinsonEssays on clinical medicine → online text (page 4 of 20)
Font size
QR-code for this ebook

tion by Dr. Loomis — narrated with all the clearness, talent, and ability
which characterize his work — we should be loath to throw aside the
instruction offered by the close study of his cases. Inasmuch, how-
ever, as I have seen, I believe, disastrous results follow this kind of inter-
ference; and when these results could not, in my judgment, be properly
explained by the natural development of the renal disease, it is only


right that I should endeavor to seek for the cause of this discrepancy.
I have allowed my reasons to be seen in part in my foregoing remarks,
and I would further add that whenever the convulsive seizure of acute
uraemia is evidently directly occasioned by a spasmodic condition of the
vessels of the kidneys, and this spasm is more or less general in the
bloodvessels of the body, including in many cases the cerebral mass and
the medulla oblongata, I have little doubt that the remedial effects of
morphine injections, in tiding over a most critical period of disease, are
very remarkable. But let us bear in mind, as the perusal of Loomis's
cases and numerous others will distinctly show, that the convulsive seiz-
ures were accompanied with dilated pupils and a more or less disturbed,
perhaps weak, heart action. Moreover, in the coma which habitually
follows just such attacks, after the use of morphine, or sometimes,
indeed, without its use, the pupil may become of pin-hol* size, or very
much contracted ; the heart maybe laboring just as much, or even more,
and the kidneys may not secrete an increased quantity of urine. I
regard such cases as being among those in which the system is even more
overwhelmed with the so-called ursemic poison than the previous ones,
and to which I would fain direct closest attention.

In this translation of the immediate or prolonged effects of renal in-
sufficiency, of systemic poisoning thus occasioned, whether occurring in
Bright's disease or in mere functional disorder, we must look to several
concealed factors involved in the clinical estimate which we should
make. In one aspect, the kidney is nothing more than an ordinary
filter ; in another, it is an elective filter, depending, no doubt, for this
power in part upon the precise anatomical and pathological conditions
affecting it ; depending also upon dynamic or vital forces, in regard to
which we are almost in the dark even at the present day. Suffice it to
add, however, that strictly scientific investigations, more particularly of
Feltz and Ritter and of Bouchard, have shown how various are the
poisonous ingredients of the urine, and how it is that at different times
the kidneys will allow some of these poisons to pass through them, and
again will not. Besides, the effects of the retained poisons are very
different according to their nature — some doubtless accounting more
than others for the pupillary and nervous symptoms ; some producing
excitement, others depression, lowered temperature, somnolence, and

These different poisons may also be eliminated from the economy even
at short invervals in unequal amounts, and, of course, different morbid
effects are thus produced, or similar effects in the unequal degree, in view
of the combined nature or quantity of the retentions in the economy.

We should also be now convinced of another fact, and it is that
neither the condition of the kidneys nor the heart, as shown by patho-
logical researches, will prove satisfactorily, in many instances, the cause


of the ursemic symptoms or seizures. We are, therefore, forcibly com-
pelled to look for the source or primary cause of the symptoms elsewhere,
and it is often in the digestive tract that we shall most certainly find
them. The control of the quality and quantity of the ingesta ; the
proper and prolonged neutralization of poisons continuously produced
in this system, will thus become a means of prophylaxis against ursemic
developments of milder or greater intensity, which will be found second
to none. So soon as the most urgent symptoms of acute uraemia are
neutralized or antagonized, judicious antisepsis of the digestive tract is
a treatment which has the greatest value. Among drugs useful in
carrying out this remedial indication, I would speak favorably, from
repeated experience, of salicylate of bismuth and beta-naphthol.

In conclusion, I would add that I am convinced in very many such
case3, especially among the residents of our cities, in the winter time,
oxygen gas by inhalation several times daily, plays a very important
remedial role. Banishment to a warm, equable climate for the cold or
variable months of the year is, of course, generally speaking, a far better
substitute than artificial inhalations of oxygen ; but this plan, I regret
to say, is often wholly impracticable.


Onk always writes about a subject which has been considered
frequently with some hesitancy. No doubt this depends upon several
facts : First, we feel we have nothing, it may be, very new to add to our
common stock of knowledge ; or, we are persuaded that no matter how
carefully we may study and observe what we see daily, similar work has
been done by men of acute mind and long training in our profession,
and that they have left very little to be said by those who come later in
the day. Moreover, we know that the work we are familiar with is often
of the best kind, and we are careful lest our little offering be regarded as
insignificant in character and in bearing. Still, it is given to every
earnest worker to note things which have some new aspects, and which
may be estimated in an individual manner, which is at times both inter-
esting and instructive to his readers.

One of the facts which is most prominent in my estimate of organic
affections of the heart is that which shows the little need, at times, of
treating heart disease merely because a murmur is present. How often
does this exist without symptoms ! How frequently an accidental exam-
ination reveals it ! Why, then, treat it? We must, first of all, consider
the patient. If accompanying the murmur there be rational symptoms
of cardiac incompetency, such as pain, dyspnoea, palpitations, and if to
these be added hypertrophy or dilatation, there can be no question that
properly instituted medication may be of great service and relieve all
distress for a while. In administering drugs we must recognize, however,
that we give them for the purpose of relieving symptoms or diminishing
the complicating conditions, not to cure chronic valvular disease ; once
the latter is well established it is there to remain, and our effort should
be not to cure, but to prevent it from becoming really injurious by
reason of its possible effects.

Perfect compensation in chronic disease is what we wish, and seek to
attain when it is broken. When it is present no treatment is required.

One great cause, as we know, of most valvular affections is rheu-
matism. Sometimes, with all the care we can exercise in the manage-
ment of this affection, cardiac disease will accompany its acute course,
or follow sooner or later as a lamentable sequela. And yet it frequently
seems to us, if the disease were managed with more care and intelligence,


as though there might be fewer instances of heart disease. Different
treatments of acute rheumatism have been thought to lessen the liability
to intercurrent or later cardiac complications. My own tendency has
always been to give an alkaline treatment, sometimes by means of
bicarbonate of soda and Rochelle salts in moderate, frequently-repeated
doses, sometimes with acetate of potash and chloride of ammonium.
Either of these combinations appears to me preferable to the use of the
salicylates in neutralizing the bad effects of acute rheumatism. I have
occasionally been of the opinion that the duration of the disease in its
acute form was thus lessened. I am confident that the pain of the
disease is frequently diminished in a marked degree. In a few cases,
where the temperature is high, the pulse bounding, I have used additions
of small doses of aconite to the second mixture for a few days, with
apparently very good effects. Of course it is important each day during
the active stage of the disease to watch closely the condition of the heart ;
sometimes endocarditis will betray itself easily by a marked increase of
local pain, dyspnoea, fever, general prostration. Not seldom it is only
by the closest attention that we can discover the beginning of the valvular
inflammation. It is very important, however, to recognize it when it is
present, for by its careful management at the period of its inception, we
can ward off the chronic and incurable consequences which may follow
under other circumstances.

Rest in bed in acute endocarditis is all-important, so as to reduce as
far as possible cardiac activity. And not only is this confinement to bed
essential during the febrile acute stage of endocarditis, but it should be
kept up for many days after this is over and when the rheumatic pains
are no longer very pronounced. Even after the patient sits up, par-
ticular attention should be paid him, and so soon as he shows signs of
fatigue he must immediately return to bed.

Nothing gives cardiac dilatation more readily than too great strain or
fatigue after acute disease, especially when the type of it is at all severe
or it has lasted any length of time. In this respect, however, individuals
differ greatly, and what in one. case would seem even beneficial to the
patient, and allows his cure to go speedily onward, in another will appear
to retard convalescence evidently, and instead of being of service is, on
the contrary, a positive injury. The ability to discriminate between the
different powers of resistance of various individuals, in other words, to
lay down an exact measure of their vital force, is one of the difficult and
arduous problems of medicine. We can never precisely gauge it in any
two cases, no matter how much alike they seem to be, and the result is
that we frequently deceive ourselves and are led into woful error, even
when we wish most to avoid it.

No doubt hereditary tendency shows itself in some of these examples
of cardiac weakness following acute disease, and if we go into family


history closely we may obtain facts which will be of real service, by
enabling us to forewarn our patients, and thus ward off from them the
results of real imprudence and consequent heart-strain. Later on, after
a patient has left his bed, strict rules for the government of habits and
dietary are valuable, and when strictly followed are productive of good

The occupation is one of the subjects to which close attention should
be given. If it be very laborious physically or mentally, heart dilata-
tion may readily occur, and ere long the patient will give many signs of
lowered vitality and cardiac weakness. Thus it becomes a duty on the
part of the professional adviser, especially when the patient is youthful,
to inquire into what is to be his future line of work, and if it be dis-
covered to be injurious, to strike a warning note, which, though un-
heeded at the time, will, nevertheless, be thoughtfully regarded when
the patient shows signs of waning strength or lack of recuperative
power. Unfortunately, there are many people who only listen to the
physician when actual physical trouble is upon them, and then it is often
too late wholly to remedy all the disastrous consequences brought on by
inattention, folly, or ignorance. Even when the valvular disease is
clearly present, it is harmful to treat it unless cardiac compensation be

The regular routine of one's daily life alone should be carefully
watched and attended to in accord with the rules of a proper hygiene for
obtaining the best heart-power for the individual. These rules pertain
to the regulation of diet, exercise, clothing, mental occupation, bathing,
and the use of stimulants.

In order to carry out our wishes in regard to all these matters — as it
is not something that can be taken up for a while and then abandoned —
it is often wise to inform our patient as to the precise nature of his
trouble, so as to make him readier to follow exactly the regimen that we
shall mark out for him, and thus attain the nearest approach to a con-
dition of continuous cardiac compensation. It is, however, often
hazardous to tell a patient that he has heart disease. If he is very im-
pressionable he becomes thoughtful about himself, nervous, excitable,
and highly apprehensive. Once such patients have acquired the idea
they have heart disease they continue to be unhappy and melancholic
despite our best efforts to relieve their minds and quiet their fears. And
yet in many cases we can truthfully affirm that if a certain line of con-
duct be pursued, health and well-being will almost surely follow. There
need be no reasonable basis for the fear that physical disability will
surely follow, or that death sooner or later, before their life's work is
half accomplished, is certain to come.

Exercise in moderation in chronic heart disease is ordinarily useful ;
so long as it does not cause dyspnoea or palpitations it may be indulged


in with advantage to the patient. While this is true, it is important to
emphasize the fact that all undue strain should be carefully avoided, as
harm will rapidly result whenever the heart is in this manner unduly
taxed. According to Oertel, no system is more valuable at times in pro-
ducing curative effects than that which he lauds specially. This method
consists essentially in making the patient take daily walks up declivities
of different steepness. The exercise is thus graduated according to the
requirements of the patient. There is little doubt that when this plan
is persistently followed for a certain length of time favorable results
are frequently shown. On the other hand, some patients do not appear
to be benefited at all by these graduated exercises. The amount of ex-
ercise which can be profitably taken by different patients similarly
affected as regards their heart lesion varies greatly. One patient, for
example, can lead a very laborious life and yet be unconscious of the
fact that he has a chronic cardiac ailment until he is almost at the point
of death ; another with an affection of a like kind will feel very much
even a moderate amount of exertion, and will soon suffer if persisted in,
with notable dyspnoea and other symptoms showing cardiac distress.

In cases of children, it is sometimes difficult to determine to what
extent their play and exercise should be controlled. Of course, if we
allow them to join in all out-door sports, especially in those where a con-
test of strength or endurance is likely to occur, great risk is taken of
irremediable injury being done to an organ already diseased. If, on
the other hand, we draw the lines too closely and keep continually
watching and directing a boy or girl with respect to their ordinary
games, we are liable to irritate and annoy them unnecessarily, and in
the end do them more harm than good by awakening ever-present ner-
vous agitation or else complete indifference. Children cannot, as a rule,
be made to look at things in a cool, dispassionate way, at least for con-
tinuous periods, and must be managed somewhat differently, for this
reason, from adults. The true course, in my judgment, is simply to for-
bid absolutely certain sports, such as foot-ball, rowing races, tennis con-
tests, etc., and to permit walking, riding, driving, fishing, etc., which do
not specially strain the heart or call upon the energies to an excessive

As regards the dietary, of course individual idiosyncrasy is to be con-
sidered, and mainly because I have found so many differences in indi-
viduals as to what kind of food suited them best ; and yet we must in
general insist upon what is wholesome ; viz., roast and broiled meats, no
rich sauces, condiments, or made dishes. The ordinary fresh vegetables
may be allowed, avoiding as far as possible those that are canned. Pota-
toes are often injurious, as they produce flatus and are difficult of diges-
tion. Alcohol is bad in anything but a limited amount. It may be
given in moderation at meal-time to stimulate appetite or promote diges-


tion ; more than this will probably occasion some gastric catarrh, which
is decidedly prejudicial by injuring the powers of assimilation. Tobacco
should be avoided, as a rule, as it is so apt to render the heart irritable
and produce palpitation and cardiac distress. Very rarely in ray ex-
perience has it been evidently useful; when it is advantageous it seems
to be in individuals of somewhat plethoric habit and highly nervous
organization, where it quiets and soothes nervous erythism. Even
then, the tobacco should be of the mildest quality, and smoking
should only be indulged once a day and after meals, particularly
dinner. At other times, tobacco may be said to be almost invariably
injurious. Tea and coffee are also to be taken in small quantities and
not too often ; either of these may be allowed at breakfast according to
the taste and habit of the individual. After-dinner coffee or tea should
not be taken, as they often disturb a night's rest, and thus bring on a
condition of bodily discomfort which is nowise compensated for by
the temporary exhilaration which is felt after their use.

I object, as a rule, to cold baths for those who suffer from heart dis-
ease, as I find they are apt to cause functional disturbance; still there
is positive good sometimes in having slight cutaneous reaction after the
bath, which can only follow where there has been a slight shock at first.
This shock ought not to be marked, but only enough to make the patient
feel brighter and more elastic after the bath than previous to it. When-
ever even this small amount of cutaneous stimulation is followed later
by uneasy precordial cool sensations, baths should be intermitted, and
only tepid or warm baths taken every morning. Sometimes it is prefer-
able to order the bath to be taken at bedtime, as it promotes sleep and
quiets restlessness. In regard to the preferable time of day, we must
learn which is best by trials, as I have found that individual preferences
must be considered. It is sometimes more judicious to allow a bath
only every other day, as the daily bath seems to weaken the patient, and
he is notably less active when it is too frequently taken. For this
reason I am inclined to recommend sponge baths, rather than full tub-
baths, as the former excite somewhat nervous force, while the tub-baths
are relaxing and seem in some cases, at least, to lessen vitality. Hot-
water baths, hot-vapor baths, or Turkish baths, are all to be studiously
avoided. The risk from them is very great, especially in regard to
cerebral hemorrhage. There are times, of course, when it is essential to
promote diaphoresis in this manner. When this is the case and a hot-
air bath is given, the head should remain outside the hot air, so that
respiration may be freely carried on. Cold applications should also be
made frequently or constantly to the head during the time of the bath,
so as to lessen any tendency there may be to cerebral congestion.

In general terms, clothing must be suited to climatic conditions, and
woollen or merino undergarments should be worn. This instruction to


wear flannel next to the skin is very important in cardiac disease, as such
patients are peculiarly sensitive to changes of temperature, and their
bodily heat is often at a low figure. Moreover, the slightest chill may
cause a bronchial attack, which, if at all severe, may become very
threatening, even to life. It is preferable to have the underwear light
in weight, as well as warm, otherwise the patient is often oppressed
and rendered uncomfortable. I have known such patients from wear-
ing too heavy flannels to be at times in a profuse perspiration, which
of itself is weakening and renders them liable to contract numerous
acute diseases which may at any moment become complications of a
grave nature. Some authors advise against heavy overcoats, which
oppress by their weight. My judgment is that with our mode of living
and changeable, uncertain climate, the only wise plan for patients with
cardiac disease to follow is to have outer garments of different weight
and texture, which they can change easily and according to temperature,
dampness, and direction from which the wind blows. One thing must
be constantly kept before one's mind, viz., that these patients often radi-
ate a small amount of heat relatively, and this deficit must be supplied
by extra covering. Their circulation is deficient, and this is shown by
the lower bodily temperature, particularly of the extremities, which
are often cyanosed, cold, and clammy. The patients in cold weather
and at night will suffer very much from cold. No matter how many
bed-clothes we may cover them with, they complain for quite a length
of time of inability to get warm. I know of no means, indeed, of re-
storing bodily heat as effectually as to put hot bottles to their feet or to
either side of the trunk.

These patients should lead placid, quiet lives, free from mental worry
and anxieties. All emotional excitements are bad. Not only will sud-
den or prolonged mental strain greatly exaggerate the previous cardiac
condition and render the prognosis graver ; it will of itself at times oc-
casion evident heart disease. Such instances are numerous and accurately
recorded. In time of war, particularly, they have been carefully noted
and studied. In our own country during and subsequent to the War of
the Rebellion numerous cases of heart disease were described. It is an
undoubted fact that the mental disquietude which existed, particularly
among raw recruits, was an efficient cause of heart disease. Da Costa
has placed on record these cases with great precision of detail and with
broad appreciation of the causation and treatment.

Most authors of works or articles on organic heart disease refer also
to similar instances which occurred during the terrible days of the
French Revolution at the time of the reign of terror in Paris and the

Constipation must be attended to ; and even though the bowels move
regularly, an occasional purgative dose will help relieve the first appear-


ance of nervous congestion of the different internal organs in an effective
manner. The sort of purgative dose to be used is often an indifferent
matter. A little Hunyadi or Friedrichshall water once or twice a week
in the morning is frequently the simplest and easiest way of meeting the
indication. With those who have a marked bilious tendency, a dose of
calomel and soda, followed in a few hours by a draught with Rochelle
salts, seems to give the patient new life after a few copious alvine dis-
charges have carried out the system a mass of effete and waste mate-
rial which was a mere source of obstruction to the satisfactory working
of the different organs of the body.

Whenever the patient is pale, or his appetite is poor, it is indicated to
give small doses of the simple bitters before meals, combined or not with
a mineral acid. If the patient be a young person, one of the iron
preparations is often useful. Of these, the choice may be considerable :
The tincture of iron agrees with many remarkably well, and except for
its disastrous effects upon the teeth should be usually ordered when an
iron preparation is indicated. As it is, I avoid giving it unless there is
some very special indication for its use, and much prefer either dialyzed
iron when the stomach is peculiarly sensitive, or pills of the proto-
chloride of iron under other circumstances.

Prior to the use of the iron salts, it is essential to get the stomach and
digestive tract in proper shape. If there be any evidence of catarrhal
inflammation of the gastro-intestinal tract, a recurrence for a few days
to some agreeable saline mixture in the morning will enable us to get
obvious and useful effects from the preparations of iron.

It is thought by some writers that iron should not be given, ordinarily,
to people of middle life or advanced in years, even when their blood is
poor in quality and diminished in volume. Arsenic is at times a suita-
ble remedy, and will frequently be of great benefit in helping impaired

1 2 4 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Online LibraryBeverley RobinsonEssays on clinical medicine → online text (page 4 of 20)