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in these cases we must dread, and properly so, the hidden effect of the
toxin of this disease on the muscle of the heart. It often weakens it
through structural changes, and yet the cardiac dilatation may not be
always appreciable to our physical methods of exploration. The heart
is weak in its action, the pulse very soft and depressible, and dyspnoeic
attacks show themselves upon very slight exertion or whenever the
emotions are at all excited. Such patients at times suffer from skin
eruptions, ambulant neuralgia, headaches, constipation, stomachal indi-
gestion, and abdominal flatus. The starches are very inimical to them,
as also all sweets, and diets should consist mainly of meat for many
weeks, despite the fact that for lack of exercise and open air the urine
at times is loaded with urates. .Frequently repeated doses of calomel
and soda, with a saline purge following, is the best and safest way to
combat these untoward symptoms. I have been obliged, in addition, to
administer heart tonics by the rectum where the stomach and skin were
both intolerant for a while.

Of course the endocardium may be inflamed in many of these cases,
and we may discover a true endocardial bruit, which is caused by the
roughening of both orifice and valves, mainly the mitral. But the
endocardial bruit is not what should alarm us; it is the weakening of
the heart muscle which takes place at the same time, and increases
through leakage at the mitral orifice consequent upon dilatation, the
intensity of the cardiac bruit, and is equally, or, more, indeed, the
grave expression of the rheumatic poison. Again, as I have said before,
there is no appreciable bruit at first near the apex, merely because heart
action is too weak to cause it, and later, when the patient is doing fairly
well, we hear the blowing murmur very readily. One of the difficult
problems in practice is to determine accurately the presence or absence
of the rheumatic poison, and it is only by the keen appreciation of the
patient's previous history and the tentative effects of anti-rheumatic
remedies that we may fairly obtain a conviction about it. The exami-
nation of the urine will not always prove it, as there may be a retention
of excrementitious substances in the economy, which only repeated and
most careful urinary analyses made under like conditions would deter-
mine. As to the symptoms, these are frequently of such indefinite
character that we might easily be led astray. And yet sometimes the
most powerful heart tonic is unquestionably the drug or drugs which



76 PROGNOSIS IN HEART DISEASE.

eliminate the rheumatic poison from the system rapidly and without
injuring the patient. In a certain number of cases I am confident that
I have been of far more use and given greater relief to my patient
with colchicin, ealicin, or chloride of ammonium, and acetate of potash
than I did by whipping up the heart action directly with strychnine
and nitroglycerin.

The dulness of the right first intercostal space, to which Rotch has
referred, does not seem to prove the existence of pericardial effusion as
opposed to true dilatation of the heart cavities. More than once the
hypodermatic needle has been used to determine accurately the presence
of a serous effusion, and the result has been negative. The result of
post-mortem examinations would also tend to show that in many similar
cases the heart is simply enlarged and no pericardial effusion is present.
Lees' and Broadbent's observations are especially corroborative of these
facts.

The prognosis of heart disease is, of course, much influenced by
ambient conditions and accidental circumstances. Wherever the cause
producing secondary symptoms of heart disease is one which we have
no power to change or modify, it is then very grave indeed. Where,
however, there is present some condition which we can fairly hope to
eliminate by judicious care, then our confidence is much greater that
we can help our patient very much. How often do we see an anaemic
girl who suffers terribly from cardiac distress relieved greatly by iron,
mountain air, and proper exercise? Or, again, if the aggravating
cause be cold, over-fatigue, sudden shock — all these accidental circum-
stances may lose their pernicious influence with treatment and time.
It has long been recognized that the mere intensity of a murmur is no
indication as to the gravity of a cardiac lesion. We may have a very
loud bruit, and yet the heart lesion is really slight. On the other hand,
a very serious change of orifice or valve may be indicated by a very
low bruit. In general it may be stated that it is the amount of hyper-
trophy or dilatation which marks the gravity of the murmur, and de-
spite the fact that frequently the enlargement of the heart is also a
protective power against secondary symptoms, which we most dread.
Prognosis of heart disease is also affected by the stationary or progres-
sive character of the lesion. As we know, this is a very difficult matter
accurately to determine, and we can only judge of the one or other
condition by the manifestation or not of secondary symptoms, such as
pain, palpitations, and dyspnoea, not to speak of the physical evidences
with which we are all too sadly familiar. Circumstances outside of the
heart influence prognosis ; these are age, sex, occupation, heredity, etc.

Heart disease is certainly graver in youth than it is in middle life.
Structural defects of the heart muscle are not infrequently inherited.
A laborious life, or one full of cares and anxieties, aggravates very



PROGNOSIS IN HEART DISEASE. 77

much the prognosis, whereas a life of ease is productive of a stationary
effect in the development of symptoms of heart disease. Serous effu-
sions into the large cavities indicate gravity. This is greater with
aortic than mitral disease. It is, also, of more serious import where
the effusions come on insidiously than where they develop after a sud-
den shock or accident. It is probable, in many instances, that the mere
presence of organic heart disease does not materially shorten life or
interfere notably with its reasonable enjoyment or with the fulfilment
of one's duties and responsibilities. I have taken care of several old
men and women who have unquestionably had mitral or aortic disease
during a greater portion of their adult life, and who nevertheless lived
to an advanced age. Moreover, not infrequently, they have been very
little annoyed from their heart affection, and very rarely suffered from
symptoms directly attributable to it. Even when such secondary symp-
toms did occur, through carelessness or undue exposure, by a short course
of judicious treatment they were soon again enjoying their usual health.
There is a proper application here to the conduct of insurance com-
panies. Some of these companies refuse to take any cases of heart dis-
ease ; others do so, but charge them a larger premium. Wherever there
are no secondary symptoms of heart disease or evidences of disease of
other organs, it seems to be wisdom to accept such cases in the latter
way as a proper business venture.

Cardiac enlargement, which in adolescent and adult life is most fre-
quently under the dependence of obstructive or regurgitant disease of
one or the other orifice, is often accompanied in old age with disease of
the arteries. The arterial changes are sufficient of themselves, if not
to cause intracardiac changes, at least to increase them when they have
begun. Sometimes the myocardial degeneration connected with the
increased size of the heart gives proof of its presence by distressing
symptoms. Not infrequently, however, these changes exist for a shorter
or longer period without manifesting their existence except by symp-
toms which indicate little or no gravity to the family physician. It is
only when some really alarming symptoms declare themselves that
anxiety of near relatives and-friends is awakened. I have also known
several cases in which sudden death occurred in which previously the
patient had usually enjoyed a very fair degree of health and activity.
Sometimes, it is true, that some cardiac pain, either spontaneous or
occurring after moderate exertion, of a pseudo-anginal type, had occa-
sionally been present, and yet no undue anxiety either of patient or of
loved ones had developed. At the necropsy of such patients myocar-
dial changes more or less extensive are readily made out, even with the
naked eye. The coronary arteries are frequently inelastic, hard, cal-
careous, or atheromatous. In their immediate area of distribution, and
particularly near their trunks and about the inter-ventricular septum,



78 PROGNOSIS IN HEART DISEASE.

cardiac fibres are already indistinct, pale, and fatty. Usually such
changes are accompanied by notable cardiac dilatation. It is probable
that if the symptoms of these conditions prior to death be properly
estimated much may be done to ameliorate the patient's condition, to
relieve suffering, and doubtless at times to prolong life and one's use-
fulness very much. There are instances, however, of the senile heart
with unquestionable enlargement which during life, and for many years,
have never given rise to any unpleasant symptoms, and are only re-
vealed in an accidental way when the patient is examined by a physi-
cian for some entirely different affection.

More or less precordial pain is one of the first symptoms which directs
attention to the failing heart of the aged. This pain may be slight at
first, and slowly increase, usually in an intermittent manner, or it may
develop suddenly and with great intensity. In the latter instance,
ordinarily, it follows overexertion, severe mental shock, or exposure.
It is accompanied with marked intermittence or irregularity of both
pulse and heart beats. These symptoms may be temporary or lasting.
Whenever they come on suddenly, and where some accidental circum-
stance sufficiently explains their advent, we may be hopeful that with judi-
cious care they will disappear sooner or later. Where, on the contrary,
they have developed slowly and somewhat insidiously, they are of seri-
ous augury, and usually indicate intracardiac changes, which will prob-
ably lead to the development of even graver symptoms. Wherever
the lower limbs become oedematous and the serous cavities contain fluid
in notable quantity it is very seldom that any therapeutic agents can
ward off the approaching fatal termination for many months. We
must insist, therefore, upon the great importance of watching carefully
the first expression of cardiac inadequacy in old age, and guard against
its rapid increase by such means as we have at our disposal. In this
place I wish to direct attention to a formula which has long been
known as the diuretic wine of the Hotel Dieu, or Trousseau's wine.
It is essentially composed of digitalis, squills, juniper berries, acetate
of potash, and white wine. In dessert or tablespoonful doses, repeated
from three to eight times in twenty-four hours, I have seen it occasion-
ally effect temporary good results which were very remarkable. Indeed,
I have known it occasionally to effect a cure which lasted several years,
where the patient was seemingly before its use (and where many other
combinations had been previously resorted to without avail) in a very
critical condition. Cardiac palpitations and tremor cordis are symp-
toms of the senile heart which, although distressing, do not as a rule
augment the gravity of prognosis. It is a singular fact that cardiac
palpitations do not affect old people nearly so often as they do the
young. Is this due to the greater impressionability of adolescents, and
particularly young women ? Tachycardia may be due to some poison,



PROGNOSIS IN HEART DISEASE. 79

like alcohol, tobacco, tea, or coffee, affecting the pneuraogastric and
diminishing its restraining influence. In such instances a prolonged
period of abstinence will usually effect a decided improvement, and not
infrequently a permanent cure. There are instances, however, in which
the nervous poison has become so deep-seated that the distress and dis-
ability to the patient are never entirely gotten rid of. Of course,
where the increased action of the heart is dependent upon structural
changes, already clearly manifest in the heart itself, we cannot properly
expect long-continued benefit from any remedial agents, although even
here we should always be willing to recognize how imperfect our mere
physical explorations may be, and how often our deductions therefrom
are later on invalidated by the patient's evident improvement. I can-
not emphasize too strongly the fact that we should never despair, even
in advanced years, to secure benefit more or less lasting by the wise use
of remedies. Not that we actually delay or prevent the advance of
serious disease in these very grave cases, but we certainly do at times
give most pronounced relief to the mere functional disablement, and
this, after all, is the great role of the practitioner in cardiac thera-
peutics.

I am thoroughly persuaded that very many physicians err grievously
in their use of the so-called cardiac tonics. Very often they are given
in too large doses ; again, they are given in combinations which are
unintelligent, mainly because they are "shot-gun" prescriptions, with-
out a definite idea as to what they are doing ; and, finally, because no
proper appreciation is paid to the physiological effects of combining
remedies which possibly neutralize one another's beneficial action. Small
doses frequently repeated, simple remedies in a thoroughly assimilable
form — these should be essential considerations in our prescribing.
Whenever we endeavor too suddenly to give power to an already over-
taxed heart the danger is evident that we often actually overstep the
mark and cause directly a fatal termination, while with keener medical
insight we should be really useful. The bearing of the preceding re-
marks upon prognosis is clear. Heart disease, not necessarily threaten-
ing, managed foolishly by a tyro or an ignoramus, may become very
grave, and imminently so. Heart disease, similar in degree and char-
acter, managed by the wise, censervative practitioner, has a wholly
different outlook. It is too much the fashion of our time in matters of
medicine to believe that the same remedies given by two different men
will effect the same result. They will do nothing of the sort. Take a
very ordinary illustration, and yet one which strikes the mind forcibly,
from a very different sphere— viz., the cook and cookery.

A French chef, with his savant gastronomic tastes and education,
will produce from a few simple materials an excellent, appetizing, nour-
ishing dish. An ignorant, self-satisfied, and hence daring cook will



80 PROGNOSIS IN HEART DISEASE.

usually spoil and make utterly uneatable and most indigestible dishes
from the very same viands. So it is with good and bad practitioners in
affections of the heart. In the one case we see amelioration, great and
enduring, perhaps, effected ; under different care the downward path is
rapid and certain. In instances where we have marked cardiac slow-
ness the intracardiac changes are more frequent than where the heart
action is unduly rapid. On this account this condition carries with it
ordinarily a graver prognosis. In many instances, fortunately, the
gouty dyscrasia seems measurably to affect the slowness of the heart
beat, and by proper eliminative remedies we can often accomplish excel-
lent results. I am confident torpidity of the liver in many such cases
is a primary factor in this slow heart action. The portal circulation
becomes clogged, and the more easily, no doubt, on account of inter-
stitial changes which are present in the liver, just as they are in the
kidneys, and are but a development of structural conditions that age
produces almost of necessity.

Give minute doses of calomel and soda, gray powder, several times
repeated in the course of a week or two, and soon everything which
caused immediate anxiety is often greatly improved. For a long-con-
tinued course of treatment it is wisdom to abandon the mercurials, and
institute in their place frequent doses of podophyllin, ipecac, soda, and
rhubarb. After such course we shall often see senile hearts practically
rejuvenated for a time at least, and a new lease of life and its enjoy-
ment quietly entered upon. In certain examples, where the gouty ten-
dency is clearly defined, and where, particularly, symptoms of angina
may be present, I would insist upon the use of Contrexeville water. I
esteem that the profession is under obligations to Dr. D'Estrees for his
advocacy of this water, and already in my experience I have seen sev-
eral cases in which the gouty condition has been favorably modified in
a very striking manner by its continued use for many weeks. The
elimination of uric acid from the economy by its action seems at times
exceptionally great. In all cases of senile heart our prognosis should
be carefully guarded, and, as Balfour says, we must shrink from dog-
matism. If we make too positive statements as to the immediate out-
come of the disease we are very liable to be mistaken. There are
usually so many modifying and attendant factors to change influencing
conditions that we should add extreme caution to our every assertion.



MINOR FORMS OF CARDIAC DILATATION. 1



Cardiac dilatation in a pronounced degree, due either to organic
valvular disease or to obvious myocarditis — acute or chronic — is no
doubt recognized and properly treated by the average good and care-
ful clinician. This affection in its minor degree is frequently con-
founded with some other ailment, or when recognized not given its
due importance, and hence ignored so far as active direct treatment
is concerned. Cardiac dilatation when at all advanced may usually be
recognized, as we know, by the usual methods of physical examination.

Percussion shows increased cardiac dulness, especially in a lateral
direction ; palpation finds the heart impulse lessened in force, more dif
fuse, and the locality of the apex-beat often somewhat changed, and
not always readily determined. Inspection corroborates these findings
more or less well. The use of the stethoscope in addition reveals feeble,
irregular heart sounds. The two sounds of the heart resemble one an-
other more nearly — the long pause is shortened. We may or may not
have a soft blowing murmur at the apex of the heart, and this murmur,
usually systolic, may also be diastolic. The pulse is rapid, irregular,
depressible, as a rule. It may be very infrequent. Dyspnoea, palpita-
tions, and occasional precordial pain as symptoms of cardiac dilatation
are not unusual. Now and then we have in most pronounced cases
blueness of lips and fingers, obstructed general venous circulation, and
oedema of the lower limbs. The foregoing is a brief picture of cardiac
dilatation in its advanced stage.

As I meet it in minor forms in my daily rounds of practice it does
not appear precisely after the manner, and I have been often misled as
to its presence and significance. One very ordinary type is that of the
anemic girl just past the age of puberty. She suffers often from too
profuse menstruation, constipated bowels, and gaseous eructations from
the stomach ; she has little or no appetite, and is constantly tired and
nervous. The heart fluttering and irregularity (subjective), which goes
with these symptoms we recognize, and yet how seldom do we consider
the heart action in these instances as being indicative of organic change
which must be treated properly and effectually if we are to obtain good
curative results. Such cases require iron and oxygen, rest and massage,
proper diet, and restricted hours of mental effort. They also require

1 Read before the Association of American Physicians, Washington, 1900.



82 MINOR FORMS OF CARDIAC DILATATION.

still more, and in the beginning of treatment it is absolutely essential,
small repeated doses of digitalis and nux vomica until their hearts
respond forcibly or at least with power sufficient to enable us to make
satisfactory use of the other means to restore bodily activity. How
shall we recognize such cases ? Oftentimes with much difficulty, unless
we appreciate rather obscure clinical facts. There is no diffuse or
weakened cardiac impulse. On the contrary, the heart apex-beats in
the fifth interspace below and inside the nipple line. It may be of
good force and not at all irregular. Abnormal sounds are not always
present. There may not be any marked accentuation of the second
sound. As a rule, however, the action of the heart is more frequent
than normal, and the first sound is exaggerated, seemingly irritable.
Give these patients for a week or two digitalis and strychnine in mod-
erate doses, and follow them with a prolonged course of iron, and we get
our best results. Act differently, and we are disappointed in our effort,
time and again, to relieve symptoms and improve the general health.

One of the proofs, as I believe, which show the correctness of my
diagnosis is that frequently in these cases the urine is light colored, of
low specific gravity, containing neither albumin nor casts, and it may or
may not be in sufficient quantity. Rest in bed will change this urine
so far as color, density, quantity, and the elimination of urinary solids
are concerned. It will also be effected and more rapidly sometimes with
rest, sometimes without, by the use of suitable cardiac tonics in very
moderate doses.

I know such a condition is often attributed to impairment of the
nervous tone, or perhaps to hysteria. So, indeed, it is at times, but
behind this frequently is the loss of a certain amount of cardiac mus-
cular power. The cavities of the heart are doubtless slightly enlarged,
and particularly that of the left ventricle, and the walls thinned. There
is no hypertrophy, and why ? Simply because there is not sufficient
vital energy to produce it. The power of the heart can only be increased
in one or two ways : by general corroborant treatment, or, at first, by
suitable cardiac stimulation, and subsequently followed by the second.
The latter plan is the speedier and better one, as I believe.

Formerly in some of these cases I was at times in reasonable doubt
for a while as to whether I had to do with beginning renal changes of
interstitial nephritis. The age of the patient, the anaemic state, and
the rapid effects of judicious treatment settle all reasonable doubts very
soon at the present time in the great majority of cases. In these
instances is the heart muscle structurally affected ? Is there granular or
other degeneration of cardiac fibres ? I do not believe so, at least in
the great number of examples, in view of the success of treatment after
several weeks or months. In other instances, where there is little or no
favorable response to rational medication, change of air and nursing,



MINOR FORMS OF CARDIAC DILATATION. 83

and where the examination of the blood by an expert shows signs that
indicate a formidable anaemia feigning the pernicious form, I am con-
vinced that we have to do with parenchymatous changes of the myo-
cardium of more or less grave import.

Is there any method by which we can demonstrate these changes to
the skeptical duriug life? Certainly not. All we can do is to reason
from analogy and our pathological findings in more serious states which
go on to a fatal termination. Fortunately, the overworked shop girl, or
the tired-out society young lady, when she gets the care required, ulti-
mately, and as a rule, gets fairly well. I have no doubt in my own
mind that in many instances perfected development or full-growth of
body reached from the twentieth to the twenty-fifth year explains the
happy termination of some cases. In other words, these cases in a
measure, may be self-limited. To the unconvinced listener who would
call such cases merely functional, I would answer : if they are then the
words of Sir Andrew Clark apropos of another topic seem to be singu-
larly suggestive and true :

"We are," writes Clark, "so much concerned with anatomical
changes ; we have given so much time to their evolutions, differentia-
tions, and relations ; we are so much dominated by the idea that in
dealing with them we are dealing with disease in itself that we have
overlooked the fundamental truth that these anatomical changes are but
secondary and sometimes the least important expressions or manifesta-
tions of states which underly them. It is to these dynamic states that
our thoughts and inquiries should be turned ; they precede, underly,


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Online LibraryBeverley RobinsonEssays on clinical medicine → online text (page 9 of 20)