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in origin. In one case I can now distinctly remember, in which Dr. Loomis was the con-
sultant, the typical signs of pneumonia disappeared within twenty-four hours under anti-
malarial treatment.


medicines, with little or no benefit. It is not always possible to make
out any cardiac murmur, but it is indicated in these cases occasionally
to give heart tonics, even more than if a loud murmur were present.
The result is indeed very surprising at times, and the cough disappears
very rapidly. 1

Instead of the rheumatic dyscrasia affecting the joints it may lodge
itself in serous membranes like the pleura or peritoneum. In attacking
the pleura it produces only slight pain at times, and for this reason,
doubtless, no recognition of the cause of cough is made out. I have also
known a case where the ear could detect little or nothing by ausculta-
tion, and yet I felt sure, through repeated observations and treatment,
that pleuritis was the cause of the cough. One or two small fly-blisters
locally applied in the beginning aborted the attack, and very soon the
patient was well. Sometimes the merely mechanical action of an en-
larged spleen or liver pressing on the diaphragm will occasion cough.
By slightly forcing these organs downward and inward, a paroxysm of
cough may also be occasionally produced. In these instances, a specially
sensitive area is found over the lower margin of the liver or spleen.

In many instances of cough of various kinds I have obtained very
great temporary relief from dry vapor inhalations of different volatile
fluids. The best combination of this kind which I have hitherto dis-
covered consists of equal parts of camphor, menthol, and eucalyptus.
This I use as an inhalation both for throat and nose. The addition of
spirits of chloroform, as we all know, to these inhalations will be found
often very useful.

In all cases of cough arising from severe bronchial inflammation, or
in those from broncho-pneumonia, I am now strongly in favor of using
inhalations of beechwood creosote mixed with steam. They are valuable
in the cure of these diseases and relieve cough very much.

No doubt the antimicrobic action of the creosote is serviceable. In
several instances of grip that I have treated I am thoroughly convinced
that the cough of this disease was diminished more with inhalations of
creosote than in any other manner. As a preventive means of treat-
ment of cough I have no doubt in my mind that a resort like Hot
Springs, Virginia, where we now are, is most useful. By making the
skin and kidneys more active, and stimulating the function of the liver,
these baths and the massage treatment which follows must render great
service. In the bracing mountain air and the dietary control exercised
by the resident physician we have additional useful influences.

1 1 meet occasionally with cases of evidently slight cardiac dilatation, characterized by a sys-
tolic bruit, which appear and disappear in a brief period. Fatigue causes them ; rest and
cardiac tonics cure them, at least for a time.


In many special treatises on diseases of the heart, especially those
which have been published in later years, the prognosis of heart disease
is pronounced less grave than it was formerly. Be it understood, how-
ever, that distinctions are made, and very properly, between the prog-
nosis of valvular defects, with and without complicating dilatation, or
structural changes of heart muscle. What is true of special treatises
is equally true of certain well-considered articles in current periodicals
on prognosis of heart disease. This is well, since formerly, as we know,
both for the public and many in our profession, heart disease once
proclaimed was also immediately stated to be incurable. In a similar
manner, if a death occurred suddenly or apparently in an unexplained
manner, heart disease was frequently made to account for it. Some-
times there was really no reason for this belief, or, again, the evidence
of previous heart disease was quite insufficient ; or, still further, while
it was known, or understood, that the dead person had during life some
" so-called " heart affection, it was not accurately determined what the
nature of the cardiac trouble was. All this was a great pity, indeed,
very damaging to the profession, because it was felt that our knowl-
edge was very imperfect. At one time, for example, a diagnosis of
heart disease was made, a serious prognosis confidently stated, and yet
the patient lived on and enjoyed very good health for many long years,
and was able without inconvenience to take part in all ordinary affairs
of life. In other instances, it is true, a similar diagnosis and prog-
nosis were made, and death, unfortunately, did occur very soon, some-
times suddenly or rapidly, sometimes after a period of several months
or years of prolonged physical disability and suffering. Evidently error,
ignorance, lack of fine discrimination and judgment, both in diagnosis
and prognosis, were responsible for this situation, and it is high time
that we should with increasing knowledge try to bring definiteness into
many important questions. It is difficult to do so wholly, as is shown
by the writings of a few, who even to-day are among our most advanced
and prominent medical writers. But it is desirable to map out as well
as possible some important relations or essential facts.

One thing is true, and may be properly admitted from the start, that
heart disease in general is quite as amenable to treatment as diseases of


other important organs of the body (Semple). Of course, if at any
time the heart stops beating for any appreciable time, death inevitably
follows ; but this statement in no way controverts the previous one any
more than to say that if the lungs do not expand death must surely
follow. Prognosis, as we know, means foreknowledge of what will
occur. It therefore takes in and declares the probable course and
sequence of a particular condition of organ. Considered in this aspect
it is indeed a part of diagnosis, and a very essential, not to say the most
important part (Broadbent).

In former times, before Laennec introduced his wonderful discovery
of mediate auscultation, knowledge of heart disease was very inaccurate,
and many judgments were very much like guesswork. Even in Laen-
nec's day, while the abnormal cardiac murmurs were recognized, their
accurate pathological significance was imperfectly determined. Now,
when diagnosis of heart disease is made, the well-informed physician
should be able to tell in advance in many instances what will surely
occur. This results from the close relationship which has been established
between clinical observation during life and the results of post-mortem
examinations. As a consequence, we can frequently warn relatives or
friends of the patient when his condition is such as to inspire real solici-
tude. We can also judge when the heart's action is no longer suffi-
cient fully to answer to the task required of it, and secondary symptoms
of its inadequacy have become manifest, that a fatal result will not long
be delayed. Again, we know that in advanced aortic disease, for ex-
ample, sudden death is always more or less imminent, and the fact should
not be ignored when important family and personal affairs are in a way
to be determined, and, perhaps, acted upon in view of this knowledge.
On the other hand, we can feel confident at times that the importance
of pathological bruits is much exaggerated, and this w : rong estimate is
merely due to the fact that their consequences are misstated or misin-
terpreted. Hence, we are fortunately prevented from causing undue
anxiety or terror when there is really no reason to be specially appre-
hensive at the time the murmur is first recognized, or, later, provided
an intelligent supervision and judicious care of the person affected be
exercised. What is also true, however, and what should never be ignored,
but make us additionally careful and watchful always, is the fact that
many serious affections of the heart, where there is limited or diffuse
structural degeneration, are not infrequently present, and yet they are
never detected during life, and it is only at the necropsy that the fatal
result is clearly explained and accounted for. Whenever, in ausculta-
tion of the heart, an abnormal murmur is discovered, it is a matter
requiring careful consideration as to whether the patient should be
informed of the fact, particularly if prior to this sometimes accidental
discovery by the attending physician the patient never experienced


any unpleasant symptoms from its presence. It is clear, then, that
whilst it may be, and often is, an obvious duty to inform the nearest
kin of the evidences of heart disease which exist in an individual where
the probable consequences are serious or fatal, it is unwise to accentuate
a situation and convey wrong impressions about a thing of little moment.
Of course, it is very wrong, where the risks of a heart affection are
grave or imminent, to withhold this knowledge from relatives or friends,
and later, when the worst has occurred, then only to announce the truth
which was very truly determined by us some time previously.

It may be now fully understood that to make an accurate prognosis
of heart disease requires the highest wisdom, widest experience, and
keenest insight of disease on the part of the clinician (Broadbent). It
is this power of prognosis which wins confidence of patients more, per-
haps, than any other quality ; and whenever the future course of dis-
ease corresponds with the statements made by the practitioner it tends
in a marked degree to increase their fealty toward him, and strengthens
their recognition that in him they have found their most trusty adviser.
In a past generation, among those who have most advanced our knowl-
edge and discrimination of heart disease we should mention Bouillaud,
Stokes, Hope, and Williams. To-day these men have been ably followed
by Sansom, Balfour, and Broadbent. It is to the latter particularly
that we are largely indebted, I believe, for much knowledge we now
have to base our prognosis on probabilities which shall render our fore-
sight of the course and consequences of heart disease more intelligent
and satisfactory than it has ever been prior to the present period. To
those who are unfamiliar with his papers, I would direct careful atten-
tion to his lectures on " Prognosis in Valvular Disease of the Heart,"
delivered before the Harveian Society in 1884, and to the Lumleian
Lecture at the Royal College of Physicians on " Prognosis in Struc-
tural Disease of the Heart," delivered in 1891. As he has pointed out,
whatever makes one's prognosis of heart disease more accurate also
improves our treatment.

In the first studies of Broadbent treatment was not, however, touched
upon, and it is only at a later period in his able work on heart diseases,
published in London in 1897, that this subject is given the attention
it demands. This is true in its widest acceptation, for the reason that
we know from frequent experience that many states of the heart are
favorably influenced by treatment only when we consider fully all the
bearing which disorders alsewhere in the economy may have upon them.
We shall first consider the prognosis in valvular disease of the heart,
as these are the affections we meet with most frequently, and, moreover,
are those about which we have most accurate information. In these
affections it is important to know the valve or orifice affected, as well
as to know the stage of the disease. Thus, for example, if it be the


aortic orifice which is involved, we know the danger of sudden death
from this form of disease is only too real. Indeed, it has heen stated
by more than one eminent authority that it is the sole form of valvular
disease in which a sudden fatal result is to be dreaded. To this I can
scarcely subscribe, if I be permitted to recur to my personal experience.

Already several times T have had under my care in hospital wards
patients who were under treatment for manifestations of cardiac inade-
quacy, functionally speaking, and who died suddenly with slight pre-
monition of what would occur. It is true that in these instances the
patients were being treated for symptoms more or less disturbing, and
while we did not anticipate a fatal termination so suddenly, yet we cer-
tainly regarded the patients as sufferers. In aortic regurgitation it is
different, since, in many instances, the patient seems very well indeed,
able and willing to indulge in all kinds of recreation, or to fill an active
business life with freedom and without distress. Under these circum-
stances sudden death may occur without warning, and it is this fact,
indeed, which causes assuredly the popular dread which prevails about
heart disease.

The question as to the stationary or progressive character of the heart
lesion is also important. From this point of view, especially among old
people, aortic regurgitation would appear to be especially dangerous,
since the lesion is apt to advance rapidly, and compensatory hypertro-
phy rarely occur. Here, again, I have seen exceptions, and have under
my care a notable one at the present time. Already my patient is an
old man, and the aortic regurgitant lesion is very marked ; still, in several
years the lesion has advanced very slightly, if at all, and the cardiac
hypertrophy is very considerable, and has proved in the main satisfac-
tory. At present, it is true, my patient suffers from dyspnoea upon exer-
tion, but this is not very severe, unless he overexerts himself, and at times
it is due to his somewhat asthmatic tendency, and is more under the
immediate result of his gouty tendency than of cardiac weakness from
the valvular disease. Murmurs indicate, as a rule, the valve or orifice
affected, but do not show the gravity or the state of the lesion. Dam-
age to orifice or valve may be very considerable, and yet the murmur
may be very low and soft. We may have, on the other hand, very loud
and intense murmurs at the heart, and yet the cardiac lesion of orifice
or valve may be very slight. The soft murmur may depend simply
upon the weakness of the heart or its inability to produce a powerful
vibratory noise. If the heart gains in strength and vigor the murmur
may become more pronounced, prolonged, intense, and harsher. When-
ever the murmur is post-systolic or post- diastolic it indicates that regur-
gitation is inadequate, according to Broadbent, and that the heart valves
remain together only a very short time.

In many of these cases of systolic bruit at the apex, and especially


in those which are not conducted into the left axilla, and are somewhat
permanent in character, they are due to chronic dilatation of the heart,
which, from the point of view of the prognosis, is far more important
than an endocarditis producing mitral regurgitation. Frequently the
necropsy shows that the amount of endocarditis is small, and in any
event does not satisfactorily account for the presence of great heart
weakness, which existed previous to a fatal termination. It is the
amount of dilatation, then, of the ventricular cavities, combined with
more or less hypertrophy, which is the really important condition, and
not the endocarditis which is present in greater or less degree.

I believe that what Lees says so well in speaking of children is
equally true of adults : " Of course, the regurgitation at the mitral
orifice produces increased tension in the left ventricular cavity as well
as in the left auricular cavity, but we must never lose sight of the fact
that weakness of the heart muscle makes this condition serious, and not
the mere valvular insufficiency which precedes therefrom, or may be
increased, indeed, somewhat by endocardial inflammation. In children
both dilatation and endocarditis may be of rheumatic origin." The
gravity of the case depends more upon the inflammatory condition of
the heart muscle, especially in children, than it does upon the concomi-
tant valvular affection. Moreover, the frequency of rheumatic carditis
in children is greater than in adults. If carefully managed during and
subsequent to the acute rheumatic attack, a fatal result does not ordi-
narily follow, at least in the beginning. Later on, and before adult
life is reached, we occasionally meet with children whose hearts are
irrevocably damaged with disease of progressive nature, and do what
we may, death surely occurs before adult life is attained. In the his-
tory of such cases we usually find several pronounced outbreaks of
acute rheumatism. At the autopsy the valvular trouble may be slight,
or pronounced, but in any event the heart muscle is degenerated, as
shown to the naked eye and with the microscope. If the mitral valve
be affected, as it commonly is, the affection is rather that of insuffi-
ciency than stenosis. If pericarditis be present in children it is of
more importance, as a rule, than the endocardial inflammation. Owing
to the intimate relations of the visceral layer of the pericardium with
the heart structure beneath, structural changes are apt to extend to
and implicate considerably the heart muscle, either causing inflamma-
tion or degeneration of cardiac fibres. The gravity, as Lees observes,
proceeds in these instances from this fact, and not from the presence of
the effusion in the pericardium, which frequently is only very moderate
in degree. We can readily understand, if the heart muscle become
inflamed or degenerated, that the power of the heart action is dimin-
ished. With this diminution of power there ensue dilatation of heart
cavities and thinning of heart walls. Hence, blood accumulates in the


ventricles during diastole, and is not expelled as it should be. If nutri-
tion and rest of the child be suitably and continuously provided for,
genuine hypertrophy of heart walls may ultimately follow, and despite
notable cardiac enlargement the heart may still be able to answer satis-
factorily to its requirements. If the contrary be true, viz., if nutrition
continue at a low ebb, and the young lad or girl be permitted to exer-
cise or play imprudently, the hypertrophy which follows, if it does
follow, is of the pseudo variety, which partakes, indeed, of a subacute
or chronic inflammatory character. It is wise to bear in mind, as
has been more than once insisted upon, how important it is to combat
properly all acute or chronic manifestations of the rheumatic or other
poisons, even though they do not appear at the time to have notably
affected the heart so far as auscultation or percussion may reveal. I
am not of the opinion of those who would insist upon large doses of
the salicylates or other so-called anti-rheumatic remedies, because I do
not believe that their apparent curative effects are always obtained
without ultimate real injury to the patient. I do believe that the
dietary should be carefully watched, the emunctories of the economy,
skin, bowels, and kidneys kept in good functional order, and when the
patient's general condition permits that a change inland from the sea-
shore or from the city to the country be insisted upon. It is believed
by some prominent writers that the differential diagnosis between acute
cardiac dilatation and pericardial effusion is readily made. In my
experience this diagnosis is very difficult at times, and we are compelled
to fall back upon what we know of the results of autopsies to justify us
in our affirmations. Usually where the dilatation has come on rapidly,
and where no pericardial friction is made out, the probabilities are more
in favor of the dilatation. Again, we can usually distinguish the posi-
tion and strength of the apex beat better with a dilated heart than we
can when the pericardial sac is considerably distended. Weakness,
irregularity, and rapidity or slowness of the pulse are favorable, in my
judgment, to a diagnosis of dilatation. In chronic cases of pericarditis
where the two layers have become extensively adherent, or adhesions
have been formed between the pericardium and the pleura or medias-
tinum, these very adhesions prevent the heart from properly contracting,
and thus tend greatly to increase its dilatation. In a greater degree
even this is probably also true where the great vessels are much
constricted by old adhesions.

In many instances of acute or chronic dilatation of the heart we have
a mitral murmur, systolic as to time. If this murmur be conducted to
the left axilla, doubtless it frequently means a certain amount of endo-
cardial inflammation. In very many cases, however, it is a mere indi-
cation of the cardiac dilatation, and the mitral orifice is enlarged simply
because the left ventricle is enlarged. Such instances are frequently



encountered in general practice, and it is to their intelligent appre-
ciation and treatment that curative results are due where, without this
medical acumen, the case would go on indefinitely without a cure, or
suddenly develop phenomena of heart failure, which are alarming for a
time, and only benefited by a systematic rest cure and judicious man-
agement under the care of a wise physician and tactful trained nurse
in the course of six months or longer. In the society girl we find one
notable example of this kind of cardiac dilatation. What with lunches,
afternoon teas, dinners, late parties, and balls, where dancing is carried
on to the small hours, and bed only reached when the body is exhausted,
no wonder that loving, anxious mothers come pleadingly to the family
physician for relief. The girl is pale, anaemic, probably constipated,
leucorrhceic, or has profuse menses ; or else dysmenorrhoeic or amenor-
rhoeic ; she is always more or less fagged out and tired. She sleeps
until ten or eleven o'clock in the forenoon, takes her breakfast in bed,
swallows innumerable Blaud's pills, because haemoglobin is deficient
and the corpuscles pale, even though the blood count is fairly normal.
The urinary secretion is often colorless, of low specific gravity ; no albu-
min, no sugar, no casts, but deficient elimination of urea. In older
persons we fear interstitial nephritis. In young persons experience is
consolatory, and we know rest, moderate massage, oxygen and iron,
beef extracts and milk punches between meals, and especially some
properly formulated cardiac pill, with time, produce good results,
backed up with early hours, plenty of sleep, and change of air. These
cases occur in the older woman, also the society drudge, who, after in-
numerable social engagements, matinees, and evening operas thrown
in lavishly, gives way finally, gets filled up with stomachal and abdom-
inal flatus, becomes dyspnoeic on slight exertion, has heart palpitation,
and blue lips and finger tips in the very acute forms, and is revived at
times only with hot-water bags, mustard plasters, and hypodermatics of
digitalis, strychnine, and nitroglycerin. The urine is occasionally loaded
with pink urates, and pains of neuralgic character in different parts
of the body are no uncommon features; or, again, we have the over-
conscientious, self-sacrificiug, ever tender, loving, and far too devoted
mother ; she it is who holds the baby at night when sick and peevish,
and the nurse tired out ; she it is who looks after the older boys and
girls, when properly they should care for themselves and for her, with
ceaseless solicitude. She buys her daughter's dresses, goes with her
whenever she can to all social functions, manages her household, looks
after the servants, pays the bills, runs the bank account, rarely if ever
gets a good, genuine rest, although never so well deserved, and one day
breaks down more or less completely, only to be supported temporarily
with cocoa and strychnine, and strophanthus frequently repeated. I
cannot emphasize all these cases too strongly. They are not overdrawn,.


but are absolutely true, and only when recognized and properly cared
for does the medical practitioner get the beneficial results which he
most desires. Cardiac dilatation, vulgarly termed heart failure, is the
true diagnosis, and this condition should never be ignored.

In the cases to which I refer the prognosis is always graver where
there have been previous rheumatic attacks and where the rheumatic
poison still gives indubitable evidences of its continued presence, for

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Online LibraryBeverley RobinsonEssays on clinical medicine → online text (page 8 of 20)