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ESSAYS 
 
 CLINICAL MEDICINE 
 
 BEING 
 
 REPRINTS OF PAPERS PUBLISHED AT VARIOUS TIMES IN THE 
 
 "AMERICAN JOURNAL OF THE MEDICAL SCIENCES " 
 
 BY 
 
 BEVERLEY ROBINSON, A.M., M.D. (Paris) 
 
 CLINICAL PROFESSOR OF MEDICINE AT UNIVERSITY AND BELLEVUE HOSPITAL MEDICAL 
 
 COLLEGE ; ATTENDING PHYSICIAN TO ST. LDKE'S HOSPITAL ; CONSISTING 
 
 PHYSICIAN TO THE CITY (CHARITY) HOSPITAL, NEW YORK. 
 
 PHILADELPHIA 
 
 WILLIAM J. DORNAN 
 1903 
 
THESE ESSAYS 
 
 NOW REPRINTED IN COLLATED FORM 
 ARE 
 
 AFFECTIONATELY INSCRIBED 
 
 TO MY 
 FORMER HOUSE PHYSICIANS OF ST. LUKE'S HOSPITAL 
 
 NEW YORK, FEBRUARY, 1903 
 
CONTENTS. 
 
 Creasote as a Remedy in Phthisis Pulmonalis. (January, 1889.) . 9 
 On the Course and Treatment of Certain Ursemic Symptoms. (Octo- 
 ber, 1893.) 24 
 
 A Contribution to the Treatment of Organic Disease of the Heart. 
 
 (December, 1894.) 35 
 
 Etiology and Treatment of Certain Kinds of Cough. (November, 1895.) 58 
 
 Prognosis in Heart Disease. (December, 1899.) 68 
 
 Minor Forms of Cardiac Dilatation. (August, 1900.) ... 81 
 
 Clinical Study of Acute Myocarditis. (March, 1901.) ... 89 
 Chronic Myocarditis and Fatty Degeneration of the Heart. (June, 
 
 1901.) 104 
 
 Angina Pectoris. (February, 1902.) . 119 
 
 Tuberculous Pericarditis : Followed by Remarks upon Paracentesis 
 
 and Incision. (June, 1902.) . . . . . . . . 135 
 
 A Study of Some Cirrhoses of the Liver. (February, 1903.) . . 149 
 
CREASOTE AS A REMEDY EN PHTHISIS 
 PULMONAL1S. 1 
 
 The use of creasote in the treatment of phthisis pulmonalis dates 
 back to 1830, the year in which its was discovered by Reichenbach, of 
 Blausko, in Moravia. Later on, it fell into disuse, like some other valu- 
 able medicaments, and for nearly thirty years previous to 1877 it was 
 practically of little or no importance in the therapeutics of pulmonary 
 disease. At the date just referred to, Drs. Bouchard and Gimbert again 
 revived interest in this drug by publishing a very complete article in 
 the Gazette Hebdomadaire, of Paris/' on its beneficial effects in consump- 
 tion. They claimed for it excellent results, and for careful, learned, and 
 honest observers, their account was as nearly enthusiastic as thorough 
 work is apt to be. 
 
 Shortly after reading of the observations or Bouchard and Gimbert, 
 I began to use creasote in the treatment of pulmonary phthisis, and in 
 a clinical lecture delivered at the Bellevue Hospital Medical College, 
 and published in the Medical Record of September 21, 1878, page 223, 1 
 mention in what manner I have used it and with what results in the 
 following terms : 
 
 " For several months, both in the Out-door Department of the New York 
 Hospital, at Charity Hospital and elsewhere, I have given dessert-spoonful 
 doses of the mistura creasoti of our Pharrnacopceia to lessen the quantity of 
 sputa in phthisis. I am very much pleased with this remedy, and believe 
 it merits a very extensive trial. No doubt, in lessening the abundance of 
 expectoration, it also diminishes the frequency of cough." 
 
 At that time, I would add, I regarded creasote as being only a good 
 anti- catarrhal agent, to be ranked high amongst some analogous remedial 
 substances whose main action consisted in the diminution of the amount 
 of purulent sputa, but which had little or no curative effect upon the 
 essential lesions of pulmonary phthisis, as we understand them. 
 
 From 1878 until 1885, the year when Jaccoud's treatise on pulmonary 
 phthisis, translated by Montague Lubbock, was published, I continued 
 to make use of creasote from time to time, but without watching care- 
 fully its effects, or believing that we had discovered, in the employment 
 
 1 Read before the Association of American Physicians, Washington, 1888. 
 
 2 Pages 486, 504, 522, and 620. 
 
 2 
 
10 CREASOTE IN PHTHISIS PULMONAL1S. 
 
 of this drug, a very valuable addition to our usual medicinal means of 
 treating pulmonary phthisis. Jaccoud's statements about the advan- 
 tages resulting from the internal exhibition of creasote in this disease 
 impressed me very much, and from the time I first read them to the 
 present date I have prescribed creasote very frequently in pulmonary 
 phthisis, and, usually, with marked beneficial effects. 
 
 About the period when Jaccoud's work was first published the em- 
 ployment of antiseptic inhalations in the treatment of this disease inter- 
 ested me, and amongst the substances of which I made extensive use 
 none seemed to me of more value than creasote. A great deal of what 
 I could even now say with truth, in regard to the utility and evident 
 results of antiseptic inhalations in the treatment of pulmonary phthisis, 
 can be found by reference to a paper read by me on this subject, at 
 the second annual meeting of the American Climatological Association, 
 held in New York City, May 27, 1885, and, also, in a clinical lecture 
 entitled " Modern Methods of Treatment of Pulmonary Phthisis," 1 which 
 was delivered before the students of the Bellevue Hospital Medical 
 College, October 27, 1885, and was published in the New York Medical 
 Journal of November 14, 1885, page 535. In the issue of the Journal 
 of that date the following occurs : 
 
 " I have employed at different times a large number of inhaling fluids and 
 many different combinations. The fluid and combination to which I now 
 give the preference are creasote and alcohol, equal parts, to which I also fre- 
 quently add a like proportion of spirits of chloroform. This combination is 
 certainly very useful in allaying cough and modifying the quantity and quality 
 of the sputa in pulmonary phthisis. I, therefore, recommend it very warmly. 
 The alcohol is added to the creasote for the double purpose of diluting it and 
 making it more volatile; the spirits of chloroform are added, in view of the 
 experience of Dr. J. Solis-Cohen, of Philadelphia, to diminish local irrita- 
 tion and excessive cough. . . . Properly and judiciously employed, the 
 creasote inhalant relieves symptoms notably, and in the beginning, at least, 
 of pulmonary phthisis is, I believe, a means of decided utility, so far as the 
 possible arrest of the disease is concerned. It is important that beechioood 
 creasote be employed. . . . Precisely the way in which creasote is most 
 useful is, perhaps, difficult to state. By its antiseptic action it is possibly 
 destructive of bacilli ; by its local action and general effect it is certainly ot 
 value in combating catarrhal conditions. Where purulent cavities exist it 
 tends to destroy, or neutralize, putridity. These are certainly sufficiently 
 good reasons for its use without pursuing the inquiry further. At all events, 
 these inhalations do good. The physician notices it, and the patient affirms 
 it. In many instances they allay cough better than any cough mixture, and 
 they are certainly free from the great objection of destroying appetite, as 
 opium and morphine so frequently do." 
 
 I mention the preceding facts to show, as I trust I have been able to 
 do, that my interest in, and experience of, the good effects of creasote 
 in the treatment of pulmonary phthisis date back already several years, 
 and is by no means the outgrowth of later observations which have come 
 
 1 This paper was published in the Transactions of the Association. D. Appleton & Co., New 
 York, 1886. 
 
CREASOTE IN PHTHISIS PULMONALIS. 11 
 
 to us mainly from Germany, and at the hands of Frantzel,' Sommer- 
 brodt," Guttmann, 3 Lublinski,' etc. 
 
 And here I would like to add a word of praise for that very distin- 
 guished therapeutician, Dr. Dujardin Beaumetz, who, in his remarkable 
 work on clinical therapeutics, 5 has given corroborative testimony which, 
 in my mind, has increased the importance of creasote as a valuable 
 therapeutic addition to our ordinary arsenal for the relief of phthisical 
 patients. In the latest edition, also, of the admirable work of It. 
 Douglas Powell, 6 will be found remarks of considerable value with 
 respect to the indications for the employment of this drug. In this 
 author's observation, he has been led strongly to doubt whether creasote 
 can be given during the hectic stage in sufficient quantities to influence 
 pyrexia without running a grave risk of setting up gastro-intestinal irri- 
 tation and destroying appetite. He regards it as being of more value 
 in apyrexial conditions ; he adds, however, that " when there is much 
 local disturbance of stomach and upper bowel, small doses of creasote 
 in combination with opium are sometimes of great service." 
 
 I do not wish further to weary attention with mere bibliographical 
 research, and refer to all the observations which have been made in 
 regard to the creasote treatment of pulmonary phthisis ; suffice it to say, 
 that it has been largely praised ; that several late observers, notably 
 Frantzel, Sommerbrodt, and Guttmann, are inclined to regard it as 
 directly curative of pulmonary phthisis, at least in its initial, or first, 
 stage ; that others, on the contrary, are less favorably disposed toward 
 it, and frankly confess that they have been disappointed in it ; and have 
 discovered no reliable evidence to show that creasote has any marked 
 beneficial action over and beyond what may be obtained from several 
 other anti-bacillary agents. 
 
 Naturally, the discovery of the bacillus tuberculosis by Koch, in 
 1882, made those observers who gave it internally, or who made use ot 
 it in inhalations, or, in some rare instances, by hypodermatic or intra- 
 pulmonary injections, 7 since that date, endeavor to establish its utility 
 mainly upon its antiseptic properties and upon its power " to retard the 
 local development of tuberculosis," which is probable, if the experiments 
 
 1 Deutsche rued. Wochenschrift, No. 14, 1887. 
 - Berliner klin. Wochenschrift, No. 15, 1887. 
 
 3 Zeitschrift f. klin. Med., Berlin, 1887, xiii., 488-494; and Boston Medical and Surgical 
 Journal, August 18, 1887, p. 161. 
 
 4 Deutsche med. Wochenschrift, Leipzig, 1887, xiii. 829. 
 
 5 Le<;ons de Clinique Therapeutique, t. 2. Paris, 1885, 4th edition, p. 549 et seq. 
 
 6 Diseases of the Lungs and Pleurte, etc. William Wood & Co. , New York, 1886, 3d edition, 
 p. 307. 
 
 '< See Wien. med. Presse, 1888, xxix. 87 ; Medical News, June 23, 1888, p. 696 ; The American 
 Journal of the Medical Sciences, February, 1888, p. 179; New Medications, by Beaumetz, 
 p. 192; Lyon Medical, 1885. 
 
12 CREASOTE IN PHTHISIS PULMONALIS. 
 
 on animals of Coze and Simor, in 1883, can be relied on. 1 Hippolyte 
 Martin, 2 also, found that creasote failed to destroy the bacillus of tuber- 
 culosis, even in the proportion of 1 per 1000. This fact is said by him 
 to be equally true of salicylic acid (solution of 5 per cent.) ; bromine 
 (1 per 10,000 and 1 per 1000) ; phenic acid (1 : 1000) ; quinine and cor- 
 rosive sublimate (1:1000). In experiments 3 undertaken by C. T. Wil- 
 liams in 1883, with respect to agents which check the development 
 of bacilli most, it was found that quinine had manifest action in pre- 
 venting their development. These properties and this power are not 
 spoken of, and were not probably thought of, as they now are, by 
 Bouchard and Gimbert. They are of the opinion, however, that creasote 
 acts locally on the pulmonary lesion and produces marked eifects which 
 are also beneficial. Essentially, they believe that creasote has the effect 
 of promoting the growth of fibrous tissue around an area of consolidated, 
 or broken-down lung structure. Thus it is, with the passage of time, 
 that the cheesy infiltrations in the lungs become absorbed little by 
 little, as the softened masses (or the contents of large cavities) are 
 expectorated and the surrounding walls close in upon a relative vacuum 
 where previously necrosed tissue in a solid or liquid form was largely 
 present. 
 
 As will be seen by my own observations in a few cases later on, I am 
 inclined to share this view and believe in its exactness. 4 In regard to 
 it, Jaccoud writes as follows : " Creasote seems also to have some effect 
 upon the fundamental lesions themselves, and to promote the sclerotic 
 change by means of which recovery is found to occur in this disease." 
 (Loc. cit., p. 156.) Indeed, Jaccoud has frequently remarked, after the 
 bronchitis has disappeared and stethoscopic signs of a pulmonary lesion 
 were reduced to a minimum, that two or three months later there was 
 an evident and secondary diminution in the extent of the affected area, 
 and bronchial breathing and bronchophony on the periphery of this 
 area. These signs accompanying an evident improvement in the general 
 condition seemed to indicate evidently a sclerosis around the area of 
 pulmonary softening. 
 
 1 According to Schill and Fischer, who mixed tubercular sputa with many different sub- 
 stances and afterward inoculated them in different animals, creasote does not appear to have 
 any inhibitory action on the tubercular virus, (v. Mittheilungen aus dem K. Gesundbeits- 
 amte, 1884. 
 
 - On transformation of true or infectious tubercle into an inert foreign body under the influ- 
 ence of high temperatures and various reagents. Arch, de Phys., 1881, p. 93; Eevue de Med . 
 1882, t. ii. p. 905 ; 1883, t. iii. p. 209.— quoted by Beaumetz in New Medications, translated by 
 E. P. Hurd, M. D.— foot-note on p. 182. 
 
 s Proceedings of Royal Society, 1884, No. 221, quoted in work on Pulmonary Consumption, 
 2d ed., Philadelphia, 1887. 
 
 * This view would appear to be that, also, of Spencer, who, in speaking of the antiseptic 
 treatment of phthisis, concludes that in our treatment it is our aim to promote healing of the 
 damaged lung tissue by means of fibroid substitution. (British Medical Journal, January 28. 
 188S.) 
 
C R E A S O T E IN PHTHISIS PULMONALIS. 13 
 
 As regards the anti-bacillary effects of creasote when taken internally, 
 or by inhalation, or both combined, I have nothing new or very posi- 
 tive to offer. On two occasions, in my own experience, when ordinary 
 care had been taken by a good examiner, bacilli which previously had 
 been present in considerable numbers, subsequent to treatment had 
 notably decreased, or completely disappeared. In other cases the exam- 
 inations made did not permit me to form a reliable judgment in this 
 regard. As to whether creasote interferes with the bacilli locally, or 
 through the circulation in virtue of its antiseptic properties, or whether, 
 in addition to its promotion of sclerosis, it merely favors general nutri- 
 tion whilst acting happily upon secondary, though important, symptoms, 
 I am not prepared absolutely to affirm. I would add, however, that I 
 am inclined at present to accept the latter rather than the former 
 belief. This conviction is based mainly upon what seems to me to be 
 a fair and proper interpretation of numerous facts observed by myself 
 and others already referred to. It is important to note, however, that I 
 am now decidedly of the opinion that patients, as a rule, improve more 
 rapidly and surely upon the conjoined treatment by means of antiseptic 
 inhalations and creasote given internally than they do upon either 
 treatment by itself. I have attained this conviction by carefully watch- 
 ing the effects produced when one or other of these methods was aban- 
 doned for a time, and afterward when both were resumed and system- 
 atically used. It is probable, therefore, that in many cases the frequent, 
 or prolonged, topical application of creasote vapors to the respiratory 
 tract in a considerable area is of undoubted utility and, after a manner, 
 not very different from what I have previously described. 
 
 Another fact of great practical importance relates to the purity of 
 the drug and the source from which it is obtained. For the information 
 of those whose attention has not been directed closely to this matter, I 
 would state that in New York City (and I presume elsewhere) much 
 of the creasote which is dispensed is simply crude carbolic acid, obtained 
 from the distillation* of coal-tar oil, and commonly called " commercial 
 creasote." It has neither the color, the odor, nor the chemical proper- 
 ties of wood creasote, or, what is preferable, of the creasote which is 
 obtained from the distillation of beechwood-tar. I am glad to believe 
 that the ordinary dispenser, in making this pernicious substitution, is 
 himself a victim of ignorance and not of knavery — at least so far as 
 what pertains to the therapeutic use of the drug. And yet in moderate, 
 or large, doses, and particularly with sensitive patients, there is a very 
 great difference in the effects of the two drugs. The one, viz., carbolic 
 acid, may prove distinctly injurious, if not poisonous ; whereas the other, 
 viz., wood creasote, when judiciously employed, should be followed by 
 favorable or perhaps negative results, but rarely, if ever, by manifest 
 bad consequences. I am credibly informed that the only creasote in the 
 
14 CREASOTE IN PHTHISIS PULMONALIS. 
 
 market to-day which responds favorably to all, or most, tests of abso- 
 lute purity is that of T. Morson & Son, an English product, which is 
 mentioned on page 497 of the United States Dispensatory, and that of 
 Merck, a German product. Of the two products, Morson's is the one 
 which I prescribe and believe is purest. In order to avoid uncertainty, 
 or risk in prescribing, it is essential at present to designate definitely 
 the creasote that we wish to employ and afterward see to it that our 
 prescription is taken to a trustworthy pharmacist. 
 
 Through inattention to the foregoing necessary precautions, ia two 
 instances reported to me, somewhat poisonous effects were produced by 
 the internal use of carbolic acid, when it was intended that creasote 
 should be taken. 
 
 In my judgment, whenever creasote is prescribed it should be taken, 
 at least at the commencement of treatment, in small or moderate doses. 
 These doses should be continued a long while, or only gradually in- 
 creased. 1 If an attempt be made, especially at first, to take large doses 
 of creasote, in the majority of cases stomachal intolerance will soon 
 follow, and we shall be obliged either to diminish the amount prescribed 
 or lessen the frequency of doses, or abandon the treatment altogether 
 for a time. My experience is different from the personal experience of a 
 Russian physician, Dr. Bogdanovitch, who found no appreciable benefit 
 from small doses (half a grain four or five times a day), but who, 
 when "he began to take creasote in gradually increasing large doses, 
 beginning with four grains a day, and reaching in about two months a 
 daily dose of forty-four grains, there took place fairly rapidly an un- 
 mistakable and permanent improvement in his symptoms." 2 It is, also, 
 different from the reported observations of Sommerbrodt and Guttmann, 
 from the perusal of which Bogdanovitch took his inspiration. 
 
 The daily amount of creasote prescribed by me for adults, in private 
 practice, has varied usually from three to six minims, and continued 
 frequently many months without increase, or interruption, or any evi- 
 dence of intolerance. The ordinary dose of half a minim is repeated 
 every two or three hours. It is given with whiskey and glycerine, 
 according to the following formula, 3 which is that of Jaccoud, the sole 
 difference being that I use whiskey where Jaccoud employs cognac or rum : 
 
 R. — Creasoti (beechwood) tt\,vj. 
 
 Glycerine 3J. 
 
 Spts. frumenti • . |jij. — M. 
 
 S. — As directed. 
 
 1 This opinion is corroborated by that of Spencer (British Medical Journal, January 2S, 188S), 
 who says that the influence of the antiseptic should be continuous and prolonged. 
 
 2 British Medical Journal, March 10, 1888. 
 
 3 Whenever the mixture is taken according to this formula no addition of water is required, 
 and it reminds one, by its smoky odor and flavor, of slightly sweetened Scotch whiskey. 
 
CREASOTE IN PHTHISIS PULMONALIS. 15 
 
 In hospital practice, for convenience sake, or rather so as to give the 
 patient a sufficient supply of medicine to last until his next visit to the 
 hospital, I prescribe teaspoonful doses, each teaspoonful containing one 
 minim of creasote, and to it are added two teaspoonfuls of water. This 
 addition is made to prevent irritation of the throat in swallowing the 
 dose. It also obviates irritation of the stomach in some instances. The 
 dose is ordered every three hours, so that if it is taken with absolute 
 regularity the patient gets eight minims of creasote in twenty-four hours. 
 This is rarely the case, as, owing to sleep or other causes, one or two 
 doses are usually omitted. 
 
 The formula which I have used in prescribing creasote is a very good 
 one, as in it the creasote is perfectly dissolved and sufficiently diluted, thus 
 preventing it from being unpalatable or irritating. The perfect solution 
 of creasote and its large dilution are both strongly insisted upon by 
 Bouchard and Gimbert in their original article as being essential points 
 in rendering it acceptable to patients. In Jaccoud's formula, as slightly 
 modified by me, we obtain the well-known beneficial effects of whiskey 
 and glycerine in the treatment of phthisis. I regard it, therefore, as 
 superior to the following, which is the one adopted by Frantzel : J 
 
 R. — Creasote n\,xv. 
 
 Tinct. gentian. ....... "ixj. 
 
 Spts. vini rect. . . . . . . . 3vj. 
 
 Vini xeres q. s.utfiant §iv. 
 
 S. — Jss ter die ex aqua. 
 
 It is well to add that only pure whiskey and glycerine should be em- 
 ployed, and as the latter is frequently adulterated, and hence injurious, 
 I would indicate Price's or Bowers's glycerine as being probably the 
 best. 
 
 I have also frequently prescribed creasote in gelatine capsules com- 
 bined with cod-liver oil. These capsules are now made by several manu- 
 facturers abroad, and may be readily manufactured in the United States. 2 
 Each capsule contains about a minim of creasote. They should be taken 
 fifteen or twenty minutes after meals. At other times they are apt to 
 cause dyspeptic symptoms. Two or three at a dose mark the limit of 
 stomach toleration ordinarily, and in only one or two instances have I 
 been able to increase this number without occasioning digestive disturb- 
 ance. For these reasons the capsules do not appear to me, at present, 
 as eligible a form to prescribe creasote as the mixture of creasote with 
 whiskey and glycerine. 
 
 If creasote be administered in cod-liver oil, the amount of oil must be 
 at least one drachm to the minim of creasote, in order to obtain a proper 
 
 1 The Year-book of Treatment for 1887. 
 
 2 Already one pharmacist in New York, to my knowledge, makes them. 
 
16 
 
 CREASOTE IN PHTHISIS PULMONALIS. 
 
 dilution of this drug. Otherwise, if cod-liver oil be indicated for a 
 patient, it is desirable to give it separately, and order the creasote to be 
 taken in the manner first advised. This I have done in several instances, 
 and particularly when, despite the use of creasote, with complete stomachal 
 tolerance, there has been continual loss of flesh. 
 
 In a very large proportion of cases of pulmonary phthisis that I have 
 treated during the last year or two (and in every one of the cases herein- 
 after analyzed), whilst creasote was taken internally, antiseptic inhala- 
 tions were also used by means of the perforated zinc inhaler. As a rule, 
 in the beginning, the inhaler was worn during fifteen or twenty minutes 
 every three hours, and from ten to twenty drops of the inhaling fluid 
 were poured on the sponge of the inhaler at least three times in twenty- 
 four hours. The inhaling fluids most frequently employed by me were : 
 
 1. A combination of iodoform, creasote, eucalyptus, chloroform, alco- 
 hol, and ether, seemingly a somewhat formidable mixture in view of its 
 numerous constituents, but a very rational one when explained in detail. 
 
 2. Iodine, creasote, carbolic acid, and alcohol. 
 
 3. Creasote and alcohol. 
 
 The first one of these inhalants is a modification of one taken by me 
 from Lauder Brunton ; the second is that of Dr. Coghill, 1 and, according 
 to K. Douglas Powell, 2 " is a favorite and much used one ;" the third is 
 so far as I know, my own combination. The following are the precise 
 formulae : 
 
 R. — Iodoform i .... 
 
 . 
 
 gr. xxiv. 
 
 Creasoti .... 
 
 
 "liv. 
 
 01. eucalypti 
 
 
 Titviij. 
 
 Chloroformi 
 
 
 tr^xlviij. 3 
 
 Alcoholis astheris 
 
 aa q. s. 
 
 3ss.— M. 
 
 R . — Tinct. iodidi retherahs, 
 
 
 
 Acidi carbolici . 
 
 aa 
 
 3ij. 
 
 
 
 3j- 
 
 Sp. vini rect. 
 
 . ad. 
 
 Sj.-M. 
 
 R. — Creasoti .... 
 
 
 3j. 
 
 Alcoholis .... 
 
 . ad. 
 
 gss.— M. 
 
 I desire now to direct attention to the tabulated statement of the 
 results obtained by me from the creasote treatment of pulmonary 
 phthisis. 
 
 1 Antiseptic Inhalations in Pulmonary Affections. By J. St. Clair Coghill, M.D., Brit. Med. 
 Journal, 1881, vol. i. p. 841. 
 
 2 Loc. cit., p. 308. 
 
 3 The chloroform in this formula was originally added by me on account of its value as a 
 preventive of cough. I am glad to And that, according to Salkovvski (Deutsche med. Wochen- 
 schrift, April 19, 1888), it is also most available, from its volatility, amongst the ethylic chlorine 
 compounds, as a respiratory antiseptic. 
 
CREASOTE IN PHTHISIS PULMONALIS. 17 
 
 The total number of cases which have taken creasote mixture and 
 used creasote inhalations (simple or compound), to which I have refer- 
 ence, are: At the New York Hospital, out-patient department, 142; 
 in private practice, 19. Besides, I have an interesting letter from my 
 late house physician, at St. Luke's Hospital, Dr. Charles II. Collins, 
 who, at my request, looked carefully over the records of that institution 
 and found that during the last two years about 150 cases of phthi-i- 
 pulmonalis have there been put on the creasote treatment, and a large 
 percentage of these cases he has been able to watch. The points of 
 interest observed by Dr. Collins, and the reflections made by him in his 
 letter to me I will reproduce, after giving an analysis of my own obser- 
 vations — recorded by myself with some care. 
 
 Of the total number of 143 cases seen at the New York Hospital, 
 there were 51 cases of pulmonary phthisis at the first stage of the dis- 
 ease; 18 cases at the second stage, 18 cases at the third stage; there 
 were also 4 cases of laryngeal phthisis, 1 case of fibroid phthisis, and 1 
 case of acute phthisis. The total number of cases, therefore, in which 
 the diagnosis is mentioned of the stage and nature of the disease, is 
 93 — leaving 50 cases of pulmonary phthisis in which the stage of the 
 disease is not mentioned. Of the whole number of cases seen at the 
 out- door department of the New York Hospital, 54 were females, 89 
 were males. 
 
 Of the 93 cases mentioned, there are 47 cases in which some notes 
 were made as to the effect of treatment, of more or less value. Of these 
 47 cases, I have arranged in tabular form such data as seemed to me to 
 be of any interest. I have also done a similar work in regard to my 19 
 private cases. From these tables I shall now proceed to take such facts 
 as result from their study. 
 
 The duration of time during which these cases were treated varied 
 from one week to two years eleven and a half months. Of these 66 
 cases, 45 were males and 21 females. Thirty-seven cases were affected 
 with the first stage in a manifest manner, as shown by the physical signs 
 and the rational symptoms ; in 3 cases the physical evidences of disease 
 were doubtful or negative, although the rational symptoms pointed plainly 
 to beginning phthisis ; in 6 cases there was found an evident second 
 stage of phthisis ; in 1 it was a question whether the case had advanced 
 so far as the second stage ; in 11 cases the disease had attained the third 
 stage ; in the remaining cases the diagnosis of the stage of disease is not 
 recorded. 
 
 In cases of the first stages of the disease, 24 had their cough improved, 
 sometimes very much, sometimes only a little; in 3 cases the cough did 
 not improve; in 10 cases the cough was cured. In several cases in which 
 the cough was improved, the sleep was quieter, and previous insomnia 
 evidently depended largely upon cough and expectoration ; in a few 
 
18 CREASOTE IN PHTHISIS PULM ON" ALIS. 
 
 instances, even though the cough improved, the sleeplessness did not 
 improve, and evidently was independent of the cough. In those in- 
 stances in which the cough is stated as being cured, I cannot say in all 
 of them how long the cure lasted ; in some, I know, the cough returned, 
 but was again cured by the use of creasote in mixture and as an inhala- 
 tion. In many cases at different stages (first, second, and third) — 17 in 
 all — no mention is made of the effect of creasote on the cough. In 
 some of these instances it is possible that the question was not asked ; in 
 many of them it is probable that no mention is made, because the cough 
 remained stationary. What I say here for the cough, I should be 
 obliged to repeat for other symptoms, and I would, therefore, offer this 
 as an explanation where my silence shall point to it, without my weary- 
 ing you by similar repetition. 
 
 In 3 cases of phthisis at the second stage, cough improved either 
 slightly or very much. In the other cases it remained stationary ; in 
 no case did it increase. In 6 cases of phthisis at the third stage, the 
 cough improved notably in 4 ; in 1 the improvement was very great ; 
 in 1, instead of improving, it became worse. 
 
 As regards night-sweats at the first stage, 8 cases were cured ; 4 im- 
 proved ; 3 remained stationary ; in 1 case they increased ; in 6 cases the 
 patients never suffered from them ; in 15 cases no mention is made of 
 this symptom. At the second stage, 1 case was cured, 1 remained 
 stationary. In a doubtful case of second stage, there was great im- 
 provement in 1 instance. In 4 cases no mention is made. At the third 
 stage, 1 case was cured, 2 improved (1 greatly), 1 patient never had 
 night-sweats; in 7 there was no mention of them. 
 
 With respect to dyspnoea at the first stage, 15 cases were improved, 
 4 cured, 1 case remained stationary, 1 case never had dyspnoea; there is 
 no mention in regard to this symptom in the other cases. At the second 
 stage, 1 case was cured, 2 cases improved, 1 case remained stationary ; 
 in 2 cases no mention is made. At the third stage, 5 cases improved ; 
 in 6 cases no mention is made. 
 
 The sputa at the first stage diminished in quantity, and improved 
 notably in appearance in 18 cases; in 5 cases the sputa disappeared ; 
 in 3 cases there was no diminution in amount of sputa; in 1 case the 
 sputa increased in quantity; in 2 cases, in which bacilli had been found 
 in the sputa, later on they could not be found. In 3 cases the bacilli 
 were looked for merely to verify the diagnosis, and they were not looked 
 for later on to see if they had disappeared. 
 
 Three times the sputa did not change in appearance or quantity, but 
 were raised more easily. The changes in appearance of the sputa were 
 often quite remarkable, and from green and yellow they became white 
 and frothy ; less tenacious, less thick. When the sputa diminished in 
 quantity and were less viscid, cough decreased and sleep often improved. 
 
CREASOTE IN PHTHISIS PULMONALIS. 19 
 
 At the second stage, the sputa diminished notably in quantity in leases; 
 in 1 case, although they did not diminish much in quantity, they changed 
 their appearance for the better and became less thick and tenacious. 
 At the third stage the sputa diminished much in quantity in 4 cases. 
 
 The appetite was improved in 17 cases at the first stage ; it remained 
 stationary in 3 cases ; in no case did it notably diminish. It improved 
 in 2 cases at the second stage ; in 1 case it diminished. In 4 cases at 
 the third stage, appetite increased. In 3 cases at the second stage, and 
 in 7 at the third stage, there is no mention of the effect on appetite. 
 
 In 2 cases dyspepsia was occasioned by creasote ; in one of these cases 
 the mixture was continued, and the dyspepsia soon improved ; in the 
 other case capsules of cod- liver oil and creasote were given, and had to 
 be abandoned altogether. 
 
 In 2 cases nausea and gastralgia were evidently caused by the creasote 
 mixture, which was stopped for a while. In 3 cases the medicine caused 
 constipation, in 1 case the constipation remained the same ; in 3 cases 
 the constipation was cured by creasote mixture. 
 
 In 2 cases diarrhoea was brought on ; in 1 case there was considerable 
 pain in the bowels; in 3 cases there .was no effect on the bowels at all; 
 in 2 cases the bowels became more regular ; previously there had been 
 alternate attacks of constipation and diarrhoea. 
 
 The effect on weight was very notable in many instances. In 18 cases 
 at the first stage, there was increase of weight, the amount of increase 
 ranging from one-half pound to twenty-five pounds. Two, three, and 
 four pounds' increase was quite common. One patient gained three 
 pounds in six weeks' treatment. In 4 cases weight remained stationary. 
 In 3 cases weight was lost, in 1 of these in moderate amount (about 
 two and one-half pounds), due to an acute attack. Previous to this 
 attack, weight had been stationary. In 2 cases there was a loss of five 
 pounds ; in 1 of them four pounds were subsequently regained by three 
 weeks' use of malt and cod-liver oil. At the second stage, in 2 cases 
 there was some loss of weight; in 1 the weight remained stationary; 
 in 3 cases there was no mention of it. At the third stage, there was 
 increase of weight in 2 cases, loss in 1, stationary in 1, no mention in 7. 
 
 In a large proportion of cases — 46 in all — no mention is made of 
 haemoptysis. In 11 cases at the first stage, no haemoptysis occurred 
 during treatment; in 3 of these cases haemoptysis had occurred pre- 
 viously, small or large in amount. In 4 cases a slight or very moderate 
 spitting of blood occurred, but in all these cases one or several hemor- 
 rhages from the lungs had taken place before the creasote treatment was 
 begun. In 1 case at the second stage, hemorrhage occurred during 
 treatment ; but in this case several hemorrhages took place before treat- 
 ment was instituted. In 5 cases no mention is made of hemorrhage. 
 In 4 cases at the third stage, no hemorrhage occurred either during, or 
 
20 CREASOTE IN PHTHISIS PULMONALIS. 
 
 before treatment with creasote. In 7 cases no mention is made of it. 
 It seems probable, therefore, from the foregoing statements, that whilst 
 creasote may not, except to a very limited extent, control pulmonary 
 hemorrhage, it does not promote or occasion it, and may, therefore, be 
 given with perfect safety to those patients who are liable to these re- 
 currences, and, indeed, during the period they actually take place. 
 
 As regards elevation of temperature, no record was made in 41 cases. 
 In the others, as well as could be determined, the following is probably 
 a correct statement: In 7 cases fever was cured under creasote treat- 
 ment, viz., it disappeared and did not return during the time the patient 
 was under observation. In 9 cases fever was notably lessened. In 1 
 case of these 9, the fever returned for a time when the patient had an 
 acute exacerbation of the disease, which occurred several times during 
 many months, and did not always appear to be occasioned by impru- 
 dence, or cold, but was rather the natural outcome of the disease. 
 In 8 cases, so far as could be observed, no perceptible effect was pro- 
 duced on the fever, and it remained about stationary. In only 1 case 
 did the temperature rise whilst the patient was under treatment, and 
 then only to a slight degree. 
 
 It is fair to assume that in creasote. we have, in the treatment of 
 phthisis, an antithermic agent of no mean value. 
 
 In 35 cases there was no mention of the effect of the treatment on 
 the strength of the patients. In 26 cases there was manifest improve- 
 ment in strength. In 6 of these the strength is spoken of as " returned " 
 or " regained." In 3, as greatly improved ; in 17, as notably improved. 
 In 1 case strength remained stationary; in 4 cases strength diminished. 
 
 Pains in chest were cured 8 times; improved, 13; stationary, 2; 
 none in one instance. In 42 cases no mention is made. 
 
 Pains in throat were cured in 6 cases, improved in 7, made worse in 
 3, remained stationary in 2. In five cases patient never suffered from pain 
 in the throat ; in 43 cases no mention is made. In 1 case of cure it 
 was attributable to the inhalations. In 3 cases in which the pains in 
 the throat improved, the previous hoarseness diminished, more or less, or 
 disappeared entirely. 
 
 In the 3 cases in which the pains in the throat became worse, they 
 were thus caused by the local irritating effects of the mixture. In one 
 instance the voice became weaker and more hoarse. 
 
 The pulse is noted as being less frequent and stronger in 6 cases ; in 2 
 as normal ; in 2 as showing no apparent change and remaining frequent. 
 In the other instances no mention is made. 
 
 Generally speaking, there was no change in the appearance or amount 
 of urine passed. On only one occasion did it apparently increase con- 
 siderably in quantity, owing to the use of creasote ; on another it became 
 clearer, where previously it had contained considerable deposits of 
 
CREASOTE IN PHTHISIS PULMONALIS. 21 
 
 urates; in a third instance the urine became more turbid. On many 
 occasions it was tested for albumin; either none was found, or the amount 
 previously existing in the urine remained the same. No casts were 
 observed, in repeated examinations, which could be ascribed to the use 
 of creasote, nor did any pronounced dark discoloration occur, such as 
 may follow the internal use of coal-tar creasote. In no instance could I 
 detect the odor of creasote in the urine, and in only one did ordinary 
 tests reveal its presence. This was a case of acute phthisis in a young 
 woman who was taking at the time sixteen minims of creasote daily and 
 who was, also, making frequent use of creasote inhalations. 
 
 As regards physical signs, I have only 2 cases at the first stage, to 
 report of complete disappearance of every evidence of morbid condi- 
 tion in the lungs. In two other instances the signs improved so much 
 that it required the strictest construction not to pronounce them cured. 
 In 10 cases at first, second, and third stages, there was slight or decided 
 improvement in the physical signs revealed by careful examinations of 
 the chest. 
 
 This improvement consisted in fewer moist rales heard at the apices, 
 in diminished area of dulness, in diminution of thoracic vibrations, of 
 resonance of the voice, in softened, less prolonged expiratory murmur, 
 which was also of lower pitch. Among the cases which I have observed, 
 there have been, in my opinion, at least four apparent cures, if due con- 
 sideration be given to the effects produced on both signs and symptoms 
 of pulmonary phthisis. 1 
 
 Dr. Charles F. Collins's report, dated St. Luke's Hospital, May 30, 
 1888, reads as follows : 
 
 " In regard to the creasote treatment in phthisis pulmonalis in hos- 
 pital cases, I have gone through all the records since the treatment was 
 first begun. The notes in the cases, though accurate, are not complete 
 enough to enable me to make satisfactory tables and to draw positive 
 conclusions concerning special points. Then, also, the previous condi- 
 tion of most of the hospital cases is often very bad in respect to hygienic 
 surroundings, often suffering from want of food and rest, so that after 
 admission to the hospital when improvement takes place it is sometimes 
 difficult to isolate the special value of treatment per se. Then, too, 
 there are many cases admitted in the last stages and the condition often 
 without hope, so that any results from treatment are not looked for ; to 
 keep the patient comfortable is the only attempt by way of treatment 
 that is available. It is also in hospital cases almost impossible to avoid 
 treating specific symptoms, such as night-sweats, wakefulness, diar- 
 rhoea, etc. 
 
 1 The cases will be found reported in full in the Transactions of the Association of American 
 Physicians for 1888. 
 
22 CREASOTE IN PHTHISIS PULMONALIS. 
 
 " During the last two years about a hundred and fifty cases of 
 phthisis have been put on the creasote treatment, and a large percentage 
 of these I have been able to watch, and the following points may prove 
 of value. It never has been discovered that the drug in any way caused 
 gastric distress or intestinal symptoms. It is pleasant to take and, in 
 the formula you introduced, patients often ask for it when leaving and 
 take it for a length of time, and I have never known a patient to dislike 
 the mixture. 
 
 " As to urinary and kidney symptoms I would add the following: 
 There has never been any perceptible change in the quantity during 
 the twenty-four hours, and repeated examinations chemically of the 
 urine of patients on creasote have failed to reveal any changes ; as far 
 as I can judge, have not known it to cause albumin even though con- 
 tinued for months, and many cases suffering from renal complications 
 when admitted to the hospital show no signs of an increase of their 
 trouble in regard to urine when put on creasote treatment. 
 
 " In general, I would like to add that this mode of treatment, the in- 
 halations as well as internal administrations, seems to give better results 
 and be more available than any mode of treatment we have followed 
 out. Many cases leaving the hospital have asked for the prescription, 
 and in cases which I have been able to follow and which have con- 
 scientiously carried out treatment, as far as can be judged, there seemed 
 to be a lasting benefit and continued improvement. 
 
 "It is a matter of considerable regret that I cannot give you records 
 of a number of special cases, but on account of the conditions above 
 mentioned, truthful records of hospital patients suffering from diseases 
 of this character are always subject to many errors." 
 
 In this place, and before giving my conclusions to this paper, I will 
 add a few words which I believe are important to bear in mind. We 
 all know how readily one may be deceived by tabular statements, 
 or, indeed, occasionally by reported cases. It is so easy to prove too 
 much ! Whilst error, however, often arises from the over-valuation o± 
 a particular drug, it is possible to underestimate the utility of a real 
 addition to our curative means in this line, when judged after a similar 
 manner. Therefore it is that final remarks or reflections, more or less 
 in the form of conclusions, must frequently be added, so that a correct 
 opinion should be formed of what a writer really believes. 
 
 I am convinced, in view of what I have seen, the proofs of which I 
 have stated, and notwithstanding their imperfect character in many 
 particulars, that we have in beech wood creasote a remedy of great value 
 in the treatment of pulmonary phthisis, particularly during the first 
 stage. Not only does it lessen or cure cough, diminish, favorably change 
 and occasionally stop sputa, relieve dyspnoea in very many instances ; 
 it also often increases appetite, promotes nutrition, and arrests night- 
 
CREASOTE IN PHTHISIS PULMONALIS. 23 
 
 sweats. It does not occasion haemoptysis, and rarely causes disturbance 
 of the stomach or bowels, except in cases in which it is given in too 
 large doses. 
 
 There is a fair amount of evidence to show that by its long-continued, 
 judicious use, it may and will modify favorably the local changes in 
 pulmonary phthisis, and how it does this I have pointed out previously, 
 as far as I was able. Whether or not it has any direct anti bacillary 
 effect when given internally, or by inhalation, or both combined (the 
 latter method being, in my judgment, the most efficient one;, remains as 
 yet to be determined in a more accurate manner. It is certainly an un- 
 objectionable medicament from any point of view. It is easy of adminis- 
 tration ; it is adapted to the majority of sufferers from pulmonary phthisis 
 everywhere ; it may be used with some advantage at all stages of this 
 disease, even the most advanced, and in my experienced has proven itself 
 superior to any other medicinal treatment with which I am familiar. 
 
 That in all cases the nutrition is the cardinal factor to be always kept 
 in view in the treatment of pulmonary phthisis, no matter what method 
 or course be followed, is, I believe, as true today as it always has been 
 from the clinical standpoint, and without regard to the passing theories 
 which may be adopted in regard to the precise role or influence of mi- 
 crobes in the pulmonary structures. The words of Dujardin-Beaumetz 1 
 seem, in this connection, of much value : 
 
 "There do not exist several medications of phthisis ; there is but one, that 
 which addresses itself to the nutrition ; the others are only adjunct methods, 
 which become dangerous if they succeed in affecting unfavorably a single 
 day, a single instance, the digestive functions." 
 
 Or those other words of E. L. Trudeau : 2 
 
 " It should be kept in view that so long as the tissues present a favorable 
 nidus for the development of the bacilli, the destruction of a portion of them, 
 if this should be found feasible, would not necessarily eradicate the disease." 
 
 To the end of altering those chemical and vital changes in the organism 
 which allow of the growth of the microbe, " thus far those conditions 
 which promote bodily vigor have alone been found effectual." 
 
 1 Lemons de Clinique Therapeutique, t. 2, p. 647. - Medical News, May 5, 1S88, p. 490. 
 
ON THE COURSE AND TREATMENT OF CERTAIN 
 
 URJEMIC SYMPTOMS. 
 
 In beginning my paper I wish to say that I ana in doubt as to the 
 title of it. In some respects I would prefer to use the designation 
 " symptoms of renal insufficiency, or inadequacy " rather than " ursemic 
 symptoms." I make this statement because uraemia does not satisfac- 
 torily express, as we all know, our belief to day in regard to the precise 
 etiology of many cases in which the kidneys are no doubt at fault pri- 
 marily or secondarily. If, however, I employ the designation renal 
 insufficiency, I feel that exception may be taken to the title, as I shall 
 speak of cases in which the kidney is surely affected with well-defined 
 structural changes, and the term uraemia, as it is generally received, 
 implies this belief in the majority of instances. 
 
 In my daily routine, especially of private practice, I meet with cases 
 of the kind I shall at first try to describe, and with which doubtless you 
 are more or less familiar. The patients to whom I refer are, as a rule, 
 what are called healthy, i. e., they have no distinctly marked organic 
 changes which are discoverable in their different organs ; or these 
 changes are so slight in amount that I cannot fairly attribute major im- 
 portance to the state of one organ as compared with others, without the 
 most careful analysis of all the conditions involved. Such patients, 
 however, have habitually some little bodily annoyances which fret 
 them more or less, and from which they desire to be relieved, and they 
 naturally seek, sooner or later, the physician's care. In regarding these 
 patients at present I am satisfied that many of them suffer primarily 
 from slight renal disorder. This affection of the kidneys, mainly func- 
 tional, is at times more pronounced, and occasions symptoms which 
 hitherto we have considered under the term ursemic. 
 
 In the mildest forms of the trouble, I believe renal insufficiency is a 
 more appropriate term, particularly if we limit its proper significance. 
 I am aware that the term itself is frequently employed in descriptions of 
 uraemia, although I have not found an article or chapter in which the 
 epithet was used as the title of a recognized condition. By adopting 
 this name with this purpose, we shall be able hereafter to employ it to 
 cover a definite series of symptoms, which, in my judgment, are not 
 otherwise properly designated. 
 
TREATMENT OF UREMIC SYMPTOMS. 25 
 
 I will now narrate a few cases in my later professional experience 
 which shall serve as a text to explain my position. 
 
 Case I. — A lawyer ; widower ; fifty-five years old ; a man of large 
 frame, who has enjoyed excellent health. In the winter months he 
 suffers from nasal obstruction and formation of excess of mucus in the 
 naso-pharyngeal space, which he relieves by efforts of hawking. Patient 
 has a somewhat constipated habit, and his urine is often higher colored 
 than is normal. Frequently, however, the density and color are normal. 
 It contains at these times no abnormal ingredient. Whenever the den- 
 sity increases and the color is darker, there is a heavy deposit of pink 
 urates; but there is no albumin, no sugar, and rarely, if ever, any casts. 
 The quantity of urine voided, as a rule, approximates the normal. When 
 the color becomes dark and the density increases, the quantity dimin- 
 ishes, but not usually to any great extent The patient under the latter 
 circumstances suffers from general neuralgic manifestations, mild in form, 
 and which rapidly disappear under judicious medical management. 
 Appetite is excellent ; no dyspeptic symptoms ordinarily ; lives well, 
 but commits no excesses. Very moderate in the use of wines or distilled 
 liquors. No attacks of rheumatism or gout. He finds himself much 
 better in health when he eschews sweets and butchers' meat; feels more 
 buoyant and in better shape when his meals consist mainly of vegetables, 
 and particularly rice, and when he eats white meats, fresh fish, and eggs. 
 On several occasions, I have attended him professionally, when, without 
 knowledge of the precise cause of his attack, he has had sneezing and 
 running of the nose ; little or no fever ; slight cough ; no evidences of 
 stomachal derangement, and yet he was evidently torpid or sluggish 
 and complained of marked drowsiness. The urine at these times was 
 dark-colored and loaded with urates. A mercurial, followed by a brisk 
 saline purge, on two successive days, rest in the house, the free use of 
 natural Vichy water, and very light diet, cured these manifestations of 
 disordered function, and in a few days he resumed his occupation and 
 was as well as previously. 
 
 Case II. — A broker ; forty-two years old ; married ; thin and spare ; 
 of an energetic, resolute character ; states that several years ago he 
 passed a small mulberry calculus, but previous and subsequent to this 
 attack has had no disease for many years. His urine is habitually some- 
 what high-colored, otherwise normal ; his intestinal digestion is imper- 
 fect ; he is somewhat constipated at times ; again he has two move- 
 ments in the twenty-four hours, which are formed, but not as large as 
 would seem to be healthful, due regard being had to the amount he 
 eats. His diet is varied, abundant, but not excessive. He drinks wine 
 moderately ; he smokes, but not to excess. He is often annoyed with 
 vague pains in his abdomen which extend into the lumbar region. 
 These pains are not severe as a rule, and usually are merely uncomfort- 
 able sensations. His abdomen is perhaps slightly distended and tense, 
 but he is scarcely annoyed with flatus. The epigastrium is somewhat 
 tender on pressure, as also, occasionally, are other regions of the ab- 
 dominal cavity. There is no manifest stomachal dyspepsia. The vague 
 abdominal pains come at irregular intervals during the day, last a vari- 
 able time, and disappear quite suddenly. Patient is rendered irritable 
 and somewhat morbid by reason of his abdominal condition. He 
 is also conscious of a slight laryngeal irritation which obliges him to ex- 
 
 3 
 
26 TREATMENT OF UREMIC SYMPTOMS. 
 
 pectorate a small quantity of viscid phlegm occasionally. His tongue is 
 broad, slightly coated on the dorsum ; his skin is sallow ; his liver is not 
 enlarged. Strict regulation of the diet, as in the previous case, the 
 regular use of euonymin, podophyllin, or cascara, persistent drinking of 
 Giesshubler or Vals water, have ameliorated but not cured my patient. 
 Latterly, I have prescribed salicylate of bismuth in addition to what 
 precedes, with the hope that intestinal antisepsis thus produced would be 
 effective in controlling the symptoms of functional disturbance which I 
 have outlined and which I have been led to believe were caused by renal 
 insufficiency. 
 
 Case III. — Only a few weeks sincel was called suddenly to see a near 
 and dear relative who had been attacked with alarming symptoms of 
 obstinate nausea and vomiting, marked cardiac weakness, and with but 
 few or no evidences in the urine, except just before the fatal termina- 
 tion, of renal complication : at this time a small quantity of albumin 
 and hyaline casts was discovered. The patient was fifty-eight years 
 old, the manager of important railroad lines. He had always been re- 
 markably strong and active. Owing to great irregularity of meals and 
 the immoderate use of tobacco and whiskey, he was a sufferer frequently 
 from flatulent dyspepsia, which he relieved with large doses of bicar- 
 bonate of soda. Some weeks previous to his death he had an attack of 
 pneumonia, moderate in severity. From this attack he had nearly re- 
 covered, when, by reason of over-fatigue, anxiety, and exposure, a mild 
 invasion of acute articular rheumatism developed. The fever had dis- 
 appeared and he was almost convalescent from this disease, when, owing 
 to the immediate effects of a cold bath, the final symptoms occurred, 
 and were regarded by the family physician as evidences of Bright's dis- 
 ease. When I saw the patient I thought the kidneys were congested, 
 but secondarily to the action of a weakened heart, and were connected 
 with engorgement of the other viscera under a similar dependence. This 
 was eminently true of the lungs and liver. No doubt it was the giving 
 way, functionally, of several important organs that was the cause 
 of death. Whilst this is true, it is also highly probable that the con- 
 dition of the kidneys, which had become more and more insufficient, gave 
 the terminal features of the combined conditions, to a greater degree 
 than any other of the organs involved. 
 
 Case IV. — A broker; bachelor; thirty years old; of a nervous, 
 excitable temperament ; suffers somewhat from symptoms of flatulent 
 dyspepsia and irritable heart. His bowels are frequently torpid ; his 
 urine habitually slightly high-colored. Habits are temperate — drinks 
 little; does not smoke. No gout or rheumatism. After an elaborate 
 dinner at which he drank different wines — but not to the point of in- 
 ebriety — he went home and slept. In the early morning he had repeated 
 attacks of vomiting and diarrhoea. Accompanying these symptoms 
 there was moderate headache and annoying palpitations. His pulse 
 was rapid, weak, depressible, and irregular. His heart action was also 
 much disturbed; it was rapid, irregular, and the pulse weakened. 
 There was a soft systolic bruit accompanying the second sound over the 
 pulmonary area. Apparently the cardiac cavities were somewhat dilated. 
 The tongue was clean, and yet nausea was distressing. No tenderness 
 over the epigastrium or anywhere in the abdominal cavity. The urine 
 had been smaller in quantity since the night previous, and instead of 
 being dark in color, was very light. Under the use, first, of ammonia 
 
TREATMENT OF UREMIC SYMPTOMS. 21 
 
 and bismuth, with broths, milk, Vichy, and rest in bed, he improved 
 rapidly. Plis heart grew stronger ; his urine became more concentrated 
 and larger in quantity. 
 
 When the first symptoms disappeared, strophanthus and nux vomica 
 were added to the previous treatment. 
 
 Such cases as the foregoing may be differently designated, I am quite 
 aware, and at times are considered of little moment and scarcely worthy 
 of very careful consideration. I have known many such attacks re- 
 garded as the usual outcome of excesses of the table, and put down in 
 doubt, if we mean by that to express the idea that the liver is incident- 
 ally interfered with as to its physiological function ; but while this may 
 be true, I claim now that such cases are correctly interrupted in recog- 
 nizing that the kidneys, by their temporary insufficiency, occasion most 
 of the symptoms reported, in a very direct manner. It is also evident 
 that strengthening the cardiac contractions and giving more vascular 
 tone to the general circulation will be found useful. These indications 
 may indeed be urgent. Is it not obvious, however, that it is the reten- 
 tion in the economy of the waste substances, made suddenly enormous 
 by reason of dietary indiscretion, which brings on the threatening symp- 
 toms which require relief by all rational methods ? Nature makes every 
 effort in these cases, by frequently repeated vomiting and purging, to 
 clear the body, through these natural emunctories, of the poisonous fer- 
 menting ingesta which enter so largely as a factor in the direct causation 
 of such explosions. The rest in bed ; the gentle and continuous warmth 
 to the surface ; the liquid diet, which is the most rational diuretic as 
 well as food, the quieting effect of the ammonia and bismuth on the 
 irritated stomachal mucous membrane, and the stimulating influence of 
 the former in relieving general depression, were rapidly followed by 
 beneficial effects. As soon as practicable the heart was strengthened 
 and regulated to overcome the effects of diminished arterial tension 
 throughout the body, but particularly in the kidneys, whose functions 
 should be re-established in order to restore equilibrium to the economy. 
 
 Case V. — A maiden lady, forty-five years old, thin and spare of body, 
 passed her menopause without functional disturbances ; she has always 
 been healthy and vigorous ; has a good appetite and digestion ; bowels 
 regular ; heart action normal ; no malaria, rheumatism, or gout. 
 Patient suffers from obstinate, recurrent headaches every morning. 
 After she awakens, gets her coffee and a light breakfast, they frequently 
 disappear, or become less intense. At times they continue during many 
 hours of the day, and only disappear, completely, without apparent 
 cause, to return again the following morning. The urine is normal in 
 quantity, rather light in color, containing no abnormal substances. In 
 this case there was no cardiac hypertrophy and no increased vascular 
 tension — at least, neither one nor the other could be affirmed after 
 careful examination. Almost every rational explanation of the head- 
 aches was attempted, and on each occasion followed up by appropriate 
 
28 TREATMENT OF UREMIC SYMPTOMS. 
 
 treatment of the supposed cause, without beneficial effect. Finally, I 
 thought that imperfect elimination of the products of mal-assimilation 
 through kidneys functionally insufficient, and which possibly were 
 affected with the precursory stage of interstitial nephritis, might account 
 for the headaches. Thereupon I prescribed nitroglycerin in the ordi- 
 nary dose of one minim of a one per cent, solution every four hours, 
 and very soon the headaches were relieved, if not cured. I now felt 
 tolerably sure that my interpretation of the case was correct. 
 
 I might multiply examples of different kinds pointing to what I 
 would call insufficiency of renal excretion, with many minute details, 
 but this narrative would merely prove wearisome. 
 
 In many instances of obstinate nasal, naso-pharyngeal, laryngeal, and 
 tracheal inflammation, chronic in type, I am now firmly convinced that 
 the inactive functional condition of the kidneys is the primary cause of 
 these inflammations. An imperfect blood -supply, containing in it many 
 elements which should be eliminated through the kidneys, is rendered a 
 source of morbid manifestations in the whole mucous tract — sometimes 
 of the respiratory organs, sometimes of the organs of digestion and 
 assimilation. Doubtless, also, the renal congestion which originates, as 
 it were, this vicious circle is heightened and made more intense by the 
 blood loaded with excrementitious substances, which come to the kid- 
 neys continuously, and which, provisionally, they are unable to get rid 
 of. In such cases I have often found, after the bowels had been freely 
 moved, and the mucous linings capable of being reached with suitable 
 topical applications had been treated, that a diuretic solution, such as 
 the liquor amraonii acetatis, frequently given, produced the happiest 
 results after it had been taken during several days in a regular manner. 
 
 I have noticed the preceding conditions on several occasions follow 
 bad colds, of the nature of grippe, or attack of influenza, and in these 
 instances have assumed that the specific nature of the disorder of the 
 respiratory tract and general system had much to do with the evidences 
 later on of renal insufficiency. In other cases, in which there could be 
 no doubt, to my mind, that there were organic changes in the kid- 
 neys of the nature of chronic parenchymatous or interstitial nephritis, 
 by reason of the specific gravity of the urine, the deposit of albumin 
 frequently contained in it, and the frequency with which different kinds 
 of tube-casts were found on microscopical examination, I have found 
 the symptoms referred to in the cases reported, but seemingly of graver 
 significance, because they were united with manifest organic renal 
 changes. Almost invariably, as we know, all undue fatigue, intense 
 emotional excitement, errors of diet or drink, cold and exposure, will 
 aggravate renal disease and bring on, rapidly or slowly, disquieting 
 symptoms. Knowing the previous condition of the kidneys, we can 
 never prudently ignore this knowledge when we care for such patients. 
 
TREATMENT OF UREMIC SYMPTOMS. 29 
 
 Cask VI. — A distinguished architect Of New York has been one of 
 my patients, off and on, for at least eighteen years — indeed, during 
 nearly all my professional life. This gentleman, now over sixty years 
 of age, is a man of great industry, great talents, and remarkable pro- 
 fessional success. Once or twice in the course of every year he has an 
 acute gouty attack affecting the metatarso-phalangeal joint of the big 
 toe of one or the other foot. Sometimes these gouty attacks in the small 
 joints of the feet come on without premonition ; sometimes a bronchial 
 or slightly asthmatic attack precedes them. During the whole period I 
 have taken care of this patient he has had urine light in color, of low 
 specific gravity, containing a variable quantity of albumin and some 
 granular and hyaline casts. Whenever these bronchial, or, frankly 
 speaking, gouty attacks are upon him, and in view of my knowledge of 
 the condition of his kidneys, I am always very solicitous in regard to 
 their outcome. I have seen him when the thoracic oppression was very 
 intense, the heart beating irregularly, rapidly, and feebly, and the pallor 
 and pinched expression of the face were striking and alarming. Ac- 
 companying this condition there were disseminated moist and sonorous 
 rales in the chest, and the urine looked almost watery, and was dimin- 
 ished notably in quantity. Under these circumstances I have found 
 that repeated doses of colchicine and the free use of Fried richshall 
 water were the most useful medicinal remedies to employ. Rest in bed 
 and fluid diet were insisted upon, and in some instances counter-irrita- 
 tion or revulsion to the back was deemed advisable. Subsequent to 
 such attacks, giving up business affairs and travel were strongly 
 favored, and when indulged in, rapidly brought about a state of well- 
 being and the return to usual conditions. 
 
 In the evident gouty cases, and particularly in those where the heart- 
 action is good and the tension in the arteries not excessive, colchicine is 
 a more valuable remedy than nitroglycerin. In instances, on the con 
 trary, in which the arterial tension is well marked or excessive and the 
 heart laboring, whilst the quantity of urine is small and low in specific 
 gravity, I believe it is wise to begin treatment with nitroglycerin or the 
 nitrites. In any very alarming expression of this condition, inhalations 
 of nitrite of amyl should first be employed. We shall sometimes be 
 disappointed in the efficacy of these agents, and it is, I believe, when- 
 ever we have been committed to the error of believing that there is 
 hypertension in the peripheral arterial system, connected or not with 
 spasm in the vessels of the kidneys, or some other important viscus. 
 Frequently, the so-called increased arterial tension is merely the conse- 
 quence of atheromatous thickening of vascular walls, and the blood, 
 instead of being under too great pressure, requires increase of the vis a 
 tergo to make it circulate more freely and with greater energy. This 
 may often be attained by the use of caffein or digitalis, and as a result 
 of the effective use of one or both of these remedies, we are forced to 
 conclude that the renal phenomena proceed directly from an enfeebled 
 heart, and the true way of managing such cases is really not to make 
 
30 TREATMENT OF UKJEMIC SYMPTOMS. 
 
 so direct an appeal to the kidneys, in the first place, but rather to the 
 muscular heart-structure. In strengthening the latter we help the 
 former in a much more obvious and important manner. When, how- 
 ever, we are not quite sure to what extent the kidneys originate the 
 series of pathological events and also tend to keep them up, it is judi- 
 cious to watch very carefully the administration of digitalis. I am con- 
 vinced that whenever the renal function is remarkably insufficient and 
 the urine is greatly diminished, or perhaps wholly suppressed, we are 
 liable to have those curious phenomena in the heart- beats and in the 
 pulse, not to speak of nausea and vomiting, which show accumulation 
 of this drug and its poisonous effects upon the economy. In many 
 instances it is relatively simple to distinguish, in a differential way, the 
 part played by the two conditions relative to cause and effect. In 
 others, we are left in great and reasonable doubt, and our judgment 
 in the matter remains most uncertain. 
 
 In regard to the simple question of the amount of arterial tension in 
 the radial arteries, I know of nothing more difficult at times than to 
 accurately estimate it — one reason being, besides the one already given, 
 the amount of soft tissues about the artery at the wrist. Even with the 
 use of the sphygmograph we may be unable to decide the matter, for 
 the simple reason that tracings with this instrument are only valuable 
 when made by an expert. Otherwise, we are liable to run into very 
 great errors of interpretation. This is mainly due to the fact that it is 
 very difficult to fit the instrument on any wrist so that we can form a 
 perfect estimate of the directness and accuracy of its pressure over the 
 artery. 
 
 Case VII. — A widow, of large, bulky frame, about sixty years of age ; 
 takes very little exercise, but drives a great deal and lives most of the 
 time in the open air, in summer at Newport, in winter at Cannes. 
 She is careful with her diet, as a rule, but commits occasional impru- 
 dences in eating rich or sweet food ; almost invariably she pays the 
 penalty of these errors by nausea, stomachal distress, pallor, and a sub- 
 icteric hue of the skin. The pulse becomes weak, rapid, and depressi- 
 ble, the heart action fluttering and feeble ; sometimes the bowels are 
 torpid ; sometimes there is and has been more or less diarrhoea, amount- 
 ing to several loose movements in the twenty-four hours. I have known 
 the attacks once or twice to be of a different kind ; instead of the pre- 
 vious symptoms, the head ached intensely ; there was torpor and somno- 
 lence ; the speech was thick, the ideas came sluggishly ; the face was 
 somewhat drawn down on one side ; the pupils were contracted, and there 
 was more or less nervous irritability, as shown by slight fibrillary muscular 
 twitchings. Seven or eight years ago, at the period of these latter 
 symptoms, the urine was ordinarily of low specific gravity, moderate or 
 abundant in amount, and containing a small quantity of albumin and 
 granular casts. Although the patient had been told that her condition was 
 gouty, and this was true in a certain sense, yet she had never had either 
 a frankly determined attack of gout or rheumatism. Compound cathar- 
 
TREATMENT OF UREMIC SYMPTOMS. 31 
 
 tic pills, strophanthus, digitalis, and nitroglycerin have all been useful 
 at times, and singular to say, the use of Warburg's extract has some- 
 times enabled me to be of the most manifest benefit, when the other 
 agents completely failed. I suspected, therefore, very strongly, a malarial 
 element, without, however, being able confidently to affirm it. Some- 
 times I have thought it possible that Warburg's extract was useful 
 simply as an hepatic stimulant, and thus helped notably to relieve 
 evident ursernic phenomena. Whenever I had gotten rid of the threat- 
 ening phenomena in this case for a time, I insisted upon a milk diet, 
 koumyss, matzoon, milk and Vichy, etc.; massage daily, or every other 
 day ; oxygen inhalations and repeated doses of digitalis in tablet triturate 
 form. Every winter and spring, for several years, I have sent her to the 
 south of France, and thus far she has held her own, and, indeed, I 
 should say, to-day she is in better physical condition than she was 
 several years ago. 
 
 In the preceding case and the one narrated before it I have more 
 than once seen what I believed to be evident and pernicious effects 
 resulting from the use of even small doses of opium or morphine in 
 some form — given by the mouth, for I have never had occasion to resort 
 to the use of morphine hypodermatically in either of the preceding cases. 
 One of the interesting features in my last case is this : During the past 
 two years the character of the urine has changed in a remarkable 
 manner ; as a rule, this is no longer light-colored, of low specific gravity, 
 containing albumin and granular casts; on the contrary, it is of a fairly 
 deep color, does not generally contain any albumin, and on several 
 occasions has shown no casts when examined very carefully and by 
 expert microscopists. What is my conclusion ? Have I cured a case of 
 interstitial nephritis or not ? I will not pretend to solve this difficult 
 question. I would simply report a very interesting clinical fact in my 
 own private experience, of which there may be many in that of my 
 listeners, so far as I know. 
 
 I now wish to speak of the use of opiates, and more particularly of 
 morphine in these latter cases, whenever respiratory or other symptoms, 
 such as obstinate or distressing insomnia, seem to require their employ- 
 ment. Personally, I am and always have been much opposed to the use 
 of opiates, and especially of morphine hypodermatically, whenever used in 
 cases of chronic Bright's disease, except in very minute doses. I believe 
 I have seen it do harm so often in locking up the secretions, when just 
 the contrary was imperatively required — in bringing out further symp- 
 toms of uraemia, acute or chronic — that it appears to me reasonable to 
 abstain from this medication as long as possible. If its use is forced 
 upon me by symptoms that I have vainly endeavored to relieve by other 
 drugs which are more innocent in their effects, I always make use of it 
 with great care and watchfulness. 
 
 There are times, however, when I do not feel in this way, and where 
 ursernic symptoms are unquestionably manifest. In general terms, these 
 
32 TREATMENT OF UREMIC SYMPTOMS. 
 
 are the cases in which the heart is the weak organ primarily, and in which 
 the kidneys will be greatly helped by .cardiac stimulation of an active 
 kind. Of the numerous drugs which strengthen, quiet, and regulate a 
 weakened, dilated heart, none at times is comparable to the hypodermatic 
 use of morphine in small or moderate doses. Therefore, when this condition 
 is obviously the cause of the distressiug or threatening symptoms, I am 
 not unwilling to recur to its use. If blood pressure is low, as shown by 
 slight, imperfect arterial tension in the radials, and if the pupils are 
 normal or somewhat dilated, with the previous condition also clearly 
 denned, I am not averse to morphine medication in the manner I have 
 mentioned. Unquestionably, when thus employed, I have had no good 
 reason myself to regret making use of it. When, however, with the 
 weak, irregular, or failing heart, are also present the pulse of lowered 
 tension and the contracted pupil, then I would cry halt ! because I 
 believe these conditions often mean poisoning from retention in the 
 system of excrementitious substances of different sorts and more or less 
 poisonous, which may rapidly overwhelm the economy in their disas- 
 trous effects unless the clear indications of treatment are distinctly made 
 out and followed by the practitioner. Again, in cases where we are in 
 great and legitimate doubt — as we frequently are — despite our most 
 careful scrutiny of a given case, as to which organ, the heart or the 
 kidneys, most evidently needs immediate help — in these cases I advise 
 against morphine hypodermatically as long as possible, on account of the 
 possible immediate and great harm which may follow its use. 
 
 Alongside of these cases, and as a further development of similar 
 underlying conditions, is what we often see, i. e., ursemic convulsions 
 actually take place. The quite general teaching of more than twenty 
 years in New York City, owing perhaps more to Prof. Loomis's influence 
 as a very prominent clinician than to anyone else, has been to the effect 
 that morphine hypodermatically in large and repeated doses in acute 
 uraemia has done what no other drug with which we are familiar will do 
 It will bring the convulsive seizure to a rapid termination ; it will at 
 times prevent the recurrence of it ; it will break up arterial spasm, it 
 will thus lessen arterial pressure ; it will promote diaphoresis ; it will 
 greatly increase the bulk of the urine when this secretion is diminished 
 or almost suppressed ; it will bring back to life when hope seems almost 
 lost. 
 
 In view of the facts so graphically and forcibly brought to our atten- 
 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 
 
TREATMENT OF UREMIC SYMPTOMS. 33 
 
 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 
 torpor. 
 
 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 
 
34 TREATMENT OF UREMIC SYMPTOMS. 
 
 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. 
 
A CONTRIBUTION TO THE TREATMENT OF ORGANIC 
 DISEASE OF THE HEART. 
 
 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, 
 
36 ORGANIC DISEASE OF THE HEART. 
 
 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 
 
ORGANIC DISEASE OF THE HEART. 37 
 
 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 
 results. 
 
 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 
 broken. 
 
 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 
 
38 ORGANIC DISEASE OF THE HEART. 
 
 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 
 degree. 
 
 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- 
 
ORGANIC DISEASE OF THE HEART. 39 
 
 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 
 
40 ORGANIC DISEASE OF THE HEART. 
 
 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 
 provinces. 
 
 Constipation must be attended to ; and even though the bowels move 
 regularly, an occasional purgative dose will help relieve the first appear- 
 
ORGANIC DISEASE OF THE HEART. 41 
 
 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 
 nutrition. It may be given as arsenious acid in tablet form, or in solu- 
 tion, as we have it in Pearson's or Fowler's preparations. Moderate 
 doses only should be given daily, and after a few weeks this medicine 
 should be interrupted, either to resume it later, or else to try some other 
 medicine, with a view to giving tone to the patient who shows indica- 
 tions of impaired vigor. 
 
 Many occurrences, doubtless, of one's ordinary life, help disturb car- 
 diac compensation when it exists, and it is difficult with the wear and 
 tear of pressing occupation or interests, which can neither be ignored 
 nor gotten rid of by many persons thus affected, to follow out the strict 
 medical indications in each and every case that is brought to our atten- 
 tion. Yet when we insist emphatically how important it is in order to 
 retain a fair degree of bodily comfort to banish, as far as may be from 
 our ordinary vocations, mental worry and bodily strain, we have done 
 much toward carrying home the importance of the pernicious influ- 
 
 4 
 
42 ORGANIC DISEASE OF THE HEART. 
 
 ences when they are allowed to exert themselves. It is also true that 
 pure air, good food, gentle exercise, hygienic surroundings in what per- 
 tains to plumbing, drainage, and ventilation, are all important adjuncts 
 to continuous well-being of very many persons similarly affected. 
 
 The compensation in organic heart disease is sometimes broken sud- 
 denly, and in that case alarming symptoms may instantly arise. These 
 instances are not infrequent after great exertions in lifting heavy 
 weights, or after severe contests in athletics, where the muscular and 
 nervous system has been put on a severe strain for several hours, or 
 even days' duration. After such accidental occurrences we are often 
 called to witness and care for the evidences of acute dilatation of the 
 heart, grafted on previous existing disease. In many instances the 
 effort or strain, whether it be interrupted or continuous, may seem in- 
 sufficient almost to account for the distressing sequelse which follow. 
 Yet when we bear in mind the fact of the pre-existing state, we have 
 less reason to be surprised than we otherwise would. Under like circum 
 stances, or even when the patient was doing nothing unusual but merely 
 taking his ordinary exercise, plugging of the coronary artery has oc- 
 curred and brought on a rapidly fatal termination. 
 
 The lack of compensatory power in the heart may not be of necessity 
 rapid in its occurrence. Very frequently it comes on little by little, and 
 in such a manner that its precise initial period is doubtful. The first 
 symptoms of moment may be cardiac palpitations, more or less distress- 
 ing in character, and lasting at first but a short time, which manifests 
 itself even after slight exertion. These patients often get along very 
 comfortably when they walk on level ground, but let them try to go up 
 a flight of stairs, or a steep declivity of any kind, and immediately they 
 suffer extremely from irregular and throbbing heart pulsations. Over- 
 fatigue, a high wind, late hours, emotional strain will cause similar un- 
 pleasant cardiac fluttering, with choking sensations in the throat and 
 chest, and a thirst for air, which is so distressing at times. One of the 
 most unpleasant forms of this cardiac incompetency is that in which 
 nocturnal dyspnoea is the acute evidence of it. The patient goes to bed 
 comfortably and falls asleep. For several hours he is obviously at ease, 
 and his slumber is restful, when suddenly he awakens with a start, in 
 great mental agitation, and his heart beats are rapid, irregular, and 
 lacking in force. An alcoholic and ethereal stimulant internally with 
 warmth to the chest by means of a hot- water bag or poultice will in a 
 brief period relieve the situation immensely and restore the patient to 
 relative ease and comfort. Of course, one must be on guard in any 
 condition which seems at first to show cardiac incompetency ; not to be 
 deceived as to the cause of it. 
 
 An acute attack of stomachal dyspepsia after a late supper, flatus with 
 distention of the colon from persistent irregularities of dietary, may 
 
ORGANIC DISEASE OF THE HEART. 4-'i 
 
 cause a flatulent distention of these organs which may interfere very 
 much with the proper action of the heart through pressure or displace- 
 ment thus occasioned, and very great and immediate relief may be 
 afforded with aromatic stimulants. 
 
 In affections of the mitral orifice mere irregularity of the pulse is so 
 frequent a sign of this lesion that little importance should be attributed 
 to its presence, unless it be allied with other rational symptoms, such as 
 dyspnoea, or precordial pain — of cardiac insufficiency. 
 
 If there be a constipated condition of the bowels, a dose of licorice 
 powder at bedtime, or a saline purge with some carminative added, in 
 the morning on rising, may be all that is needed to re-establish perfect 
 comfort. If the symptoms of cardiac inadequacy continue despite the 
 rational treatment just indicated, and without further trials of other 
 medication, absolute rest in bed must be enjoined. In a very short 
 time, from this enforced quiet alone, great benefit results very often. 
 The compensatory power of the heart is rapidly re-established, and car- 
 diac irregularity may soon completely disappear. Even in those cases 
 where percussion shows pronounced dilatation with enlargement of all 
 the cardiac cavities, and there are evidences of cellular infiltration in 
 the lower limbs, the advantages of rest are unmistakable. The rest in 
 bed is of service mainly because the heart has much less work to do 
 when a patient is in repose than when he is moving about actively 
 Many thousand cardiac beats are thus prevented each day, and the car- 
 diac ganglia have an opportunity to regain their former power. Thus, 
 the heart muscle is restored from its fatigued or exhausted condition and 
 proper rhythmic explosions are developed. 
 
 Just as rest is important, so is more sleep to be induced, and in this 
 way a passing condition of incompetency is prevented from becoming 
 permanent. Of course, if any complicating condition exists which 
 evidently interferes with the patient's rapid recuperation, this should be 
 properly attended to. Among these we would mention mal-assimila- 
 tion of food, leucorrhoea, diarrhoea, bleeding piles. The mere fact of 
 arresting a weakening discharge by administering proper medicinal 
 remedies, in connection with an appropriate dietary, may be of great 
 service in promoting the cure, or great relief of the case, so far as all 
 functional disturbance is concerned. Such remarkable effects are so 
 frequently obtained by attention to the foregoing indications that patients 
 are apt to become reckless and the physician careless. The result is 
 that frequently the patients go back too soon to the mode of life which 
 has been the direct occasion of their bad symptoms, and very soon we 
 have a return of the latter in an aggravated form. 
 
 Whenever the case is that of a workingman or woman, they should 
 be particularly warned against the evil effects of sudden strains on the 
 heart, and should be told to seek, if necessary, occupations in which the 
 
44 ORGANIC DISEASE OF THE HEART. 
 
 hours of work may, perhaps, be longer, but the danger of frequent or 
 occasional occurrence of great efforts will be wholly avoided. If the 
 patient be a professional man accustomed to great mental toil he should 
 be brought to consider the necessity of an out-door life, longer hours of 
 sleep, and soothing mental distractions as far as is practicable. If the 
 patient be a lady addicted to the pleasures of fashionable entertain- 
 ments, where late suppers, dancing, and the great stress of this mode of 
 life in lessening nerve force be the custom, she must be told emphatically 
 that it is only by abandoning these pleasures that she can be restored to 
 health, and that the heart can recover healthy action in proportion as 
 the structural failure may be lessened or cured — i. e., cardiac dilatation. 
 
 In many cases, however, progress of organic disease, although pre- 
 vented for a longer or shorter period, is steadily worse. Onward and 
 downward is the march of events. Under these circumstances we are 
 obliged to depend upon drugs or other medication systematically used 
 from time to time, or continuously, to obtain an arrest of the troublous 
 effects of disease. 
 
 The remedies employed are, first, those which stimulate the heart- 
 action ; and second, those which are directly tonic or corroborant in their 
 effects, not only to the heart, but also to the blood and general system 
 as well. Digitalis easily ranks first among the former in the estima- 
 tion of the great number of clinicians, and must be given without regard 
 to the nature of the lesion whenever the heart begins to fail and is 
 unrelieved by the means previously referred to. Digitalis unquestion- 
 ably, in the great majority of cases, leads other remedies by the certainty 
 of its power and action. Whenever digitalis in small or moderate doses 
 remains without apparent good effect, and the patient is evidently ansemic 
 and has not yet reached middle life, some iron salt may be combined 
 with it. There are some instances in which the iron and digitalis once 
 begun, in order to restore the compensatory balance in the heart muscle, 
 have to be continued long periods of time and almost continuously. 
 In other instances the treatment by digitalis alone or digitalis and iron 
 combined are only required occasionally and for a few weeks on any 
 occasion to bring back the circulation to healthy activity. The effect 
 of digitalis in small doses persistently and constantly given for a while 
 is to diminish markedly cardiac dilatation, whether there be or not in- 
 sufficiency at the mitral orifice. Sometimes, as an aid to the digitalis, 
 strychnine may be advantageously combined with it. Strychnine, besides 
 stimulating the heart, is also a stimulant to the respiratory centres, and 
 this action is often valuable in view of the relations between the circu- 
 lation and respiration, independently of what is simply mechanical. 
 
 It is sometimes wise if there be a chronic lung affection, as cirrhosis 
 or emphysema, at the same time that there is notable cardiac asthenia, 
 to add carbonate of ammonia to the previous combination of strychnine 
 
ORGANIC DISEASE OF THE HEART. 45 
 
 and digitalis. Instances are not rare in which some combination of two 
 or more of these drugs has been taken for years, and when at any time 
 they were interrupted almost immediately the patient began again to 
 suffer from palpitations or cardiac distress. 
 
 No doubt in many of these cases where regurgitation at the mitral 
 orifice results mainly from mere weakness of the cardiac muscle, and 
 very little from the valvular changes, which are very slight, the depend- 
 ence of the heart upon stimulation from these drugs is very great. Evi- 
 dently, as has been shown, the mechanism for closing the mitral orifice 
 does not reside in the valve alone, but much power is present in the 
 muscular walls of the left ventricle, not only to lift the valve itself, but 
 also to diminish the mitral orifice. 
 
 As a rule, however, digitalis should be intermitted from time to time, 
 in order to obtain its best effects. Once, indeed, its bad effects produced, 
 such as nausea and vomiting, it is frequently with some difficulty that 
 we again obtain tolerance for the use of the drug. 
 
 One of the observations of Withering, who wrote about the use of 
 digitalis at the end of the last century, was that it acted particularly 
 well with dropsical patients, and when the pulse was low, feeble, irregular, 
 or intermittent ; on the contrary, when there was a tense pulse with 
 evident thickening of the arterial coats, its action was not so beneficial 
 or its diuretic action at all pronounced. This view of Withering is 
 practically somewhat our own estimate of digitalis to-day. It is gener- 
 ally admitted that it increases and lends force to the systole of the heart ; 
 at the same time, digitalis unquestionably contracts the arterioles, and it 
 is in this manner that arterial tension is increased. This double effect 
 is, as a rule, very useful in mitral regurgitation, particularly at the 
 commencement of this disease and when both effects of digitalis are 
 desirable. Later on, the action of digitalis on the arterioles is not so 
 satisfactory, especially when dropsy has set in, because this effect mili- 
 tates against its diuretic action, which is so essential at this period of the 
 disease. In order to obviate as far as possible this untoward action of 
 digitalis, we should exhibit concomitantly with it moderate doses of 
 nitroglycerin. 
 
 By the use of these drugs combined with one another we can fre- 
 quently accomplish effects at the terminal stage of a mitral lesion which 
 we can obtain in no other manner. The action of the nitroglycerin is 
 doubly useful under these circumstances. It adds to the power of the 
 heart's contractions; it dilates peripheral vessels, and thus renders these 
 contractions more effective, and thus the diuretic action of the digitalis 
 is notably increased. The amount of either one of these drug3 which 
 may be given advantageously in the condition of obstinate or increasing 
 dropsy cannot easily be determined in advance. My plan is to give, 
 say one drachm of the infusion of digitalis and ^^ gr. of nitroglycerin 
 
46 ORGANIC DISEASE OF THE HEART. 
 
 every two hours, and progressively increase both of them, if need be, up 
 to two or three drachms of the infusion of digitalis every two hours, and 
 -5*5- gr., or even more, of the nitroglycerin at similar intervals, before we 
 can obtain the most desirable effects. Everything depends upon the 
 case and the effects of the drugs. If digitalis apparently causes nausea 
 or vomiting, if the pulse under its influence, instead of becoming stronger 
 and more regular, becomes weaker, intermittent, and very slow, it is 
 time to diminish, or it may be, interrupt its use for several hours or days. 
 These indications are even more formal whenever the quantity of urine 
 remains the same and its density is unaltered. As regards the nitro- 
 glycerin, if the head throbs and pains in a notable manner, whilst the 
 pulse remains small, feeble, and uncertain, to increase its dose would be 
 of questionable utility. 
 
 It is most important in the use of these drugs to know that their 
 quality and preparation can be relied on. The tablets of nitroglycerin 
 as purchased in many drug stores are frequently unreliable, and we can 
 at times use very large doses of the drug in this form without obtaining 
 the effects we should expect from it ordinarily. It is preferable, there- 
 fore, to make use of a freshly prepared solution, graduated so as to 
 exhibit in every teaspoonful a given amount of the active ingredient. 
 The best preparation of digitalis cannot always be stated. Personally, 
 I favor the fresh infusion of the leaves in cases where I desire particu- 
 larly to procure its diuretic action. In cases where the tonic effect on 
 the heart is most important, I prefer the tincture. Moreover, the tincture 
 is such an available preparation, which we can always obtain and keep 
 ready for immediate use, that this very convenience makes us, perhaps, 
 somewhat over-i'ate its value. The fluid extract is, of course, given in 
 smaller bulk on account of its greater strength. Further than this I 
 do not believe it has* any appreciable different value from the tincture, 
 as I do not think the addition of alcohol in the tincture makes any 
 essential change in its action unless the doses given be unusually 
 large. 
 
 I am confident that the action of hydragogue purgatives is very im- 
 portant to relieve dropsy, and particularly in those cases where digitalis 
 in moderate doses and by itself has not notably increased the bulk of 
 urine. Compound jalap powder, with or without calomel, has always 
 seemed to me the most reliable among the purgatives, and I give it 
 invariably almost the preference over other means in this line when 
 treatment is begun. 
 
 Elaterium and croton oil never appear to me desirable if they can be 
 properly avoided, or if the compound jalap or scammony powders prove 
 active and beneficial. After repeated movements from the bowels, which 
 follow the use of these purgatives, the diuretic action of the digitalis 
 and nitroglycerin is shown frequently in a remarkable manner, and 
 
ORGANIC DISEASE OF THE HEART. 47 
 
 the bulk of urine is increased from a few ounces to several pints in a 
 few days. 
 
 I have no doubt that it is important in these instances not to attempt 
 giving any solid food by the mouth, for the patient will be quite unable 
 to digest it, and the only consequence of allowing it to be taken is to 
 bring on nausea or vomiting, besides causing stomachal distress, and, it 
 may be, further injuring the condition of the patient by the toxins which 
 are produced and absorbed. The diet should be a strictly fluid one, 
 and even the quantity of the fluid must be limited. It would not do to 
 allow a patient where dropsy is very considerable to take large draughts 
 of milk or water. The milk should be limited to two or three ounces 
 every two hours, and given preferably peptonized. 
 
 Unless the patient be unusually prostrated he should not be awakened 
 if he is asleep to give him his dose of milk. Of course, this severity in 
 regard to the quantity of fluids allowed should only last while the drop- 
 sical condition is very threatening. As soon as the vessels are able to 
 take up the effused serum in the tissues and cavities, owing to the drugs 
 employed and the dietary just insisted upon, the latter may be increased 
 or made somewhat more liberal. 
 
 It is especially important whenever the serous cavity contains fluid, 
 either of the chest or the abdomen, to let it out by paracentesis, or 
 otherwise the patient's chances of even temporary recovery are greatly 
 diminished. It is sometimes these repeated tappings which keep such 
 patients alive for long periods and enable them to get about once more, 
 when without them they would surely die, and that, too, very rapidly. 
 I can recall instances where withdrawal of chest-fluid on repeated occa- 
 sions had helped restore the patient, with the other agents and care 
 insisted upon, to a state of relative strength and comfort which has 
 lasted a considerable period. The same statement is true in regard to 
 abdominal puncture with withdrawal of intra-peritoneal effusion. 
 
 Of course, if there be dropsy in connection with aortic disease the 
 same treatment holds good ; but it is a well-known fact that this com- 
 plication is then infrequent, and it is far more probable to encounter it 
 with advanced mitral lesions. 
 
 Whenever the tricuspid valves have lost their ability to close the 
 right auriculo ventricular orifice, and the cavity of the ventricle is dis- 
 tended, while the muscular walls have lost compensatory power, we have 
 to do with those very bad cases in which the prognosis is gravest. With 
 pulsating, enormously distended, over-charged jugulars, with markedly 
 pronounced epigastric pulsations, and the soft blowing murmur distinctly 
 marked over the right heart, in addition to numerous other signs inci- 
 dent to this state, we have one other means besides the foregoing which 
 will help us sometimes relieve our patient, at least temporarily. This 
 final expedient is blood-letting. The vein at the bend of the elbow must 
 
48 ORGANIC DISEASE OF THE HEART. 
 
 be opened and the blood allowed to escape. A few ounces thus taken 
 will sometimes give notable relief and enable the right heart to continue 
 its beats, when without this help it would soon cease to combat the 
 increasing pressure from within from the quantity of its contained 
 blood. 
 
 It will not answer in an advanced state of incompetency, where dis- 
 tress and lack of power are marked with such intense features, to do 
 more than afford some relief in this way. If we attempt it we are apt 
 to weaken the patient too much, and the heart soon ceases to contract 
 altogether, and stops in diastole. Of course, in those cases where there 
 is acute dilatation of the right cavities in a heart as yet undegenerated, 
 and which is but the result of over-strain, the quantity of blood which 
 can be advantageously taken by venesection is sometimes very consider- 
 able, and even as much as a pint or more will, be a loss soon completely 
 replaced. Moreover, the patient's condition seems lighter and better in 
 every way from getting rid of an excess of blood, which was the greatest 
 obstacle which stood in the way of possible recovery from animmineutly 
 threatening condition. 
 
 This indication for relief of the right heart by venesection in acute 
 dilatation is not changed by the fact that there may be old bronchial 
 imflammation with emphysema ; on the contrary, in just such cases this 
 means may be our most potent one of saving life, and all other meaus 
 without it appear at times to be insufficient or unavailing. 
 
 Although the usefulness of digitalis has not been doubted in later 
 years, at least, as to its power to combat, when properly managed and 
 helped in its action by the other means which I have mentioned, the 
 dropsical condition dependent on organic heart disease, such is not the 
 invariable opinion held about the value of this drug in aortic lesions 
 where dropsy is present. Theoretically it has been considered injurious, 
 because the diastole of the heart was lengthened, and thus the disten- 
 tion of the left ventricle was said to be increased. Practically, however, 
 this judgment cannot be regarded simply because after the continuous 
 use of digitalis for some time, even in this condition, we shall note in- 
 crease in the vigor of cardiac contractions. Moreover, the pulse becomes 
 stronger and more regular, the dropsy decreases, and the bulk of the 
 urine notably augments. It is wise, however, with an aortic lesion 
 present, never to give large doses of digitalis in the beginning, and to 
 increase even a very moderate dose of the drug with great care and 
 circumspection. Upon any indication of its failing to be beneficial it 
 is only prudent to withdraw the use of the drug and substitute some 
 other cardiac stimulant in its place. 
 
 Whenever the oedema of the lower limbs continues, with other evidences 
 of dropsical effusion, and is not influenced by all previous remedies, we 
 are compelled to resort to the use of Southey's tubes or to repeated scari- 
 
ORGANIC DISEASE OF THE HEART. 49 
 
 fications, with proper antiseptic precautions to relieve their great disten- 
 tion. Without such means of relief, painful ulcers may occur, which it 
 is almost impossible to heal, and they render the patient's condition even 
 more deplorable. 
 
 A red blush over the thickened and tense skin, not unlike an erysipe- 
 latous inflammation, may occur and give additional anxiety in our 
 patient's behalf. After scarification or punctures, and when the fluid 
 has pretty well drained from the lower limbs, they should be wrapped 
 in canton-flannel bandages, which are frequently renewed, so as to keep 
 down the recurrence of the great swelling and distention. These means 
 are but temporary expedients and fail to afford more than passing relief. 
 
 According to some writers, caffein is very little to be relied upon in 
 the treatment of any form of organic heart disease. This opinion, 
 fortunately, is not general, and certainly does not correspond with my 
 own experience. In doses of one to three grains by the mouth, espe- 
 cially in the form of the citrate, by reason of its solubility, I regard it 
 as being a very excellent heart stimulant. In my judgment, as in that 
 of others, it is especially adapted to certain cases of mitral stenosis in 
 which dyspnoea is excessive and where digitalis does not seem to act 
 well. It is also very desirable to make use of citrate of caffein in com- 
 bination with strychnine in cases of aortic incompetence which do not 
 respond favorably to the action of digitalis. Caffein not only agrees 
 with the stomach very well when digitalis disturbs it given in any form, 
 but it likewise has a very marked diuretic action, particularly if the 
 kidneys are not much diseased, which may be shown, although digitalis 
 has remained inactive in this regard. 
 
 Some writers have regarded the citrate of caffein as inert when given 
 as a salt already prepared, but in this opinion I am inclined to believe 
 they are greatly mistaken. Even in the last stages of chronic heart 
 disease, this drug when given in one-grain doses hourly has been of 
 great service after digitalis has failed to produce the slightest favorable 
 impression upon the patient, and, indeed, has been followed by many 
 evidences of intoxication from retention of the drug in the economy. 
 Whenever the powers of assimilation are very imperfect, the salicylate 
 or benzoate of caffein should be employed hypodermically by reason of 
 their perfect solubility and their non-irritant local effects. 
 
 The two objections to the employment of caffein continuously in large 
 or frequently repeated doses, are first, its action in causing insomnia, 
 which, of course, is a great drawback when a patient's nervous system 
 seems to call imperatively for the influence of this great restorer of 
 bodily comfort. Again, I have known patients to become restless and 
 mentally agitated to a high degree when I have persistently used caffein 
 for several days continuously with but short intervals of rest between 
 doses. Hallucinations and delirium have occurred when a nearly poison- 
 
50 ORGANIC DISEASE OF THE HEART. 
 
 ous dose has been taken by mistake rather than premeditation. The 
 objectionable fact of these occurrences has been insisted upon by some 
 writers. 
 
 There is another remedy for failing heart about whose value there 
 seems to be just as much difference of opinion as there is in regard to 
 caffein, and that is convallaria majalis. The Russians and some distin- 
 guished observers in France and England consider it to be eminently 
 valuable. It has been said to produce evident regularity of the pulse 
 and increased force of heart-beats, with great diuretic power in cases 
 even where there was marked tricuspid regurgitation. And this action 
 may be noted after digitalis fails. Like caffein, convallaria does not 
 impair stomachal digestion, but is easily tolerated ; associated or not 
 with caffein, it seems well adapted to cases of mitral stenosis. It may 
 be given as the tincture or fluid extract. I have prescribed the drug 
 repeatedly for many years, and have been much pleased with its action 
 on several occasions when I was really despairing as to what could be 
 done to afford relief to a water-logged patient. 
 
 In mitral stenosis, the difficulty against which we are obliged to con- 
 tend is not the dilated left ventricle, to which we wish to give strength 
 and tenacity, but it is the tendency to pulmonary congestion, which throws 
 more work on the right heart. If we attempt to increase the vigor of 
 the right-heart contractions with the use of digitalis, while the lungs re- 
 main congested owing to the fact of the non-passage of a sufficient quan- 
 tity of blood through a much narrowed mitral orifice in a certain length 
 of time, the patient's distress is not relieved, but the dyspnoea from 
 which he is suffering is frequently much increased. Aconite in small 
 repeated doses is said occasionally to be of service under these conditions. 
 I have never believed this observation to be correct, at least among 
 adults ; but, on the contrary, am of the opinion that the use of this drug 
 merely aggravates the preceding condition by increasing vascular par- 
 alysis in the lungs. A far better method is to use repeated doses of 
 nitroglycerin in all urgent cases and whenever the patient has been un- 
 relieved by caffein and convallaria, and afterward to follow up the use 
 of nitroglycerin by the long-continued exhibition of strychnine or nux 
 vomica. 
 
 ^It has always appeared to me highly injudicious to make use of aconite 
 in any appreciable dose in the treatment of any condition of failing 
 heart strength, acute or chronic, particularly among adults. With 
 children I am occasionally of a different opinion ; but even such instances 
 are rare in practice, and unless a child has a febrile state concomitant 
 with the intracardiac condition, and which is apparently of ephemeral 
 nature and without evident localization, I am loath even with them to 
 give aconite, except in very small doses. 
 
 In certain cases of cardiac hypertrophy connected with or indepen- 
 
ORGANIC DISEASE OF THE HEART, 51 
 
 dent of a valvular lesion, aconite has been used by many practitioners 
 with, as they believe, obvious benefit. The cases where this action seems 
 most desirable are those in which the cardiac impulse is excessive and 
 the patient is annoyed with the throbbing and pulsation in the chest, 
 which apparently indicate excessive cardiac action. It is probable that 
 this excessive action rarely occurs, and we should be very careful, in my 
 judgment, of toning down the heart. If we must give a cardiac seda- 
 tive, I attach far more value to the use of the mixed bromides than I 
 do to aconite. 
 
 Of the bromides, I regard the salt of sodium as least likely to do 
 harm, and I am sure that I have often given this remedy in large doses, 
 3SS-3J, several times in the twenty-four hours, without occasioning any 
 cardiac depression. On the contrary, it has seemed to exercise a gentle, 
 soothing, and quieting effect, which diminished the turbulent action of 
 the heart without lessening its strength. 
 
 What is true of the bromides is also true of the valerianates — and 
 valerianate of ammonia in pill form is a most valuable adjunct to our 
 treatment in these cases. The excessive cardiac action may be attended 
 with feelings of fulness or uncertainty in the head, and the tinnitus 
 aurium from which such patients occasionally suffer is extremely annoy- 
 ing and objectionable. I have known these unpleasant sensations to be 
 greatly diminished by salicylate of soda, with a small addition of phe- 
 nacetine. Of course, the use of the latter prescription should simply be 
 made while the aural and head symptoms are actually a source of great 
 discomfort. As soon as they are dissipated we should interrupt their use. 
 
 In cardiac hypertrophy, as long as tension is kept up in the arteries, 
 the prognosis is good, because we know that the general and cardiac 
 nutrition are being sustained. Whenever this tension fails, by reason of 
 the rupture or of the insufficiency of one of the coronary cups, we know 
 that the prognosis has become serious, and that the case will progress 
 rapidly downward. Even under these conditions, we have tumultuous 
 intrathoracic throbbings, but they show not strength but weakness, and 
 that weakness is of secondary degeneration, against which we should fight, 
 not with depressant agents like aconite and veratrum viride, but rather 
 with heart tonics, like strychnine and iron, which in restoring vigor to 
 the heart-muscle, lessen its impotent struggle, as shown by the dissipation 
 of painful symptoms, which from a narrow and limited observation, ap- 
 pear to indicate nerve sedatives. 
 
 Whenever cardiac power is defective there is an insufficient quantity 
 of blood sent out by its pulsations to the arteries which distribute them- 
 selves throughout the body. Owing to this insufficient distribution of 
 arterial blood there is a marked tendency to venous engorgement every- 
 where. In the kidneys we have it, and albuminuria follows ; in the 
 stomach it is evident, and gastric catarrh results ; in the liver the venous 
 
52 ORGANIC DISEASE OF THE HEART. 
 
 portal circulation is clogged, and soon the sclerotics are yellow, the 
 tongue coated, and nausea and inappetence present themselves. With 
 this marked, recurring, or almost constant venous engorgement of the 
 viscera, fibrous changes occur in all these organs, and these permanent 
 changes weaken and cripple them in their functional power to that degree 
 finally that no remedies can ultimately afford relief, even to symptomatic 
 disturbance. 
 
 Whenever in the conditions alluded to we have called to our help 
 the power of digitalis, and instead of giving notable relief, it merely 
 diminishes the pulse-rate so as to make it abnormally slow, we should 
 abandon its use and recur to that of the other cardiac stimulants. When 
 we are assured that we have obtained good results we note easily a 
 stronger heart-beat, an increased pulse tension, and a real compensatory 
 hypertrophy. Doubtless, at the same time, the coronary arteries are 
 filled with blood, the nutrition of the heart is improved, and the arterial 
 recoil accentuated. 
 
 One of the bugbears of many practitioners relates to the so-called 
 cumulative action of digitalis. As a fact, there is no more danger of this 
 with digitalis than there would be in the case of many other heart tonics, 
 if they were injudiciously managed, as is true whenever digitalis is followed 
 by sudden poisonous effects of marked severity. Digitalis does not elimi- 
 nate itself from the economy rapidly ; and, of course, if we give large 
 dose3 of it in short periods of time we may get untoward effects, just as 
 we might if we gave arsenic or belladonna frequently, and without allow- 
 ing time enough for their physiological elimination from the body. I 
 must protest, however, against the notion still common with some prac- 
 titioners, that digitalis has a way of its own of lying dormant for a while, 
 and afterward appearing suddenly, and springing, as it were, upon the 
 poor victim, who will show signs of poisoning from its use. This idea is 
 very erroneous, and should be combated forcibly whenever it appears. 
 Of course, in certain forms of heart disease but for mechanical reasons, 
 as in hypertrophy, we should be very temperate in our use of digitalis, 
 or else we would do great damage. On the other hand, in cardiac dila- 
 tation it is more than doubtful whether we could really poison an indi- 
 vidual with this drug unless we gave excessive, almost unjustifiable, doses. 
 Even in cardiac dilatation, however, the use of digitalis must be inter- 
 mitted when we have obtained desirable effects, or else we may occasion 
 a return of cardiac palpitation and irregularity of the heart. Sometimes, 
 with the presence of cardiac dilatation, we may have a cardiac systolic 
 murmur at the apex, and after digitalis has been taken for a while the 
 murmur disappears. This simply means that the cardiac ostium has 
 become smaller through ventricular contraction so as to permit the 
 valve to be competent once more. Again, sometimes, a murmur which 
 did not exist at first, with evidences of cardiac dilatation, may become 
 
ORGANIC DISEASE OF THE HEART. 53 
 
 distinct after the continuous use of moderate doses of digitalis, and yet 
 all the rational symptoms of cardiac incompetence previously observed 
 by the patient have greatly improved or entirely disappeared. This 
 means merely that the heart has obtained renewed power, that the mus- 
 cular contraction of the heart-walls is greater, and that the blood when 
 thrown through the enlarged or diseased orifice gives a murmur which 
 was not noticed previously, because the heart had not force sufficient to 
 produce it. The ventricle in the latter case also may show signs of 
 diminution as to volume as well as increased force in its dynamic 
 function. 
 
 There are many states of cardiac asthenia, as those resulting from 
 effort or great and sudden shock, in which it is nearly impossible to 
 recognize at once, or indeed, until the patient has been carefully ob- 
 served for several days or weeks, what amount of disturbance is purely 
 functional and what amount is occasioned by organic heart changes. 
 Murmurs, intermittences, cardiac irregularities, combined with weakness 
 of heart action, afford, at least, sufficient reasons to be doubtful as to the 
 r6le each may play in the condition presented to us. Careful physical 
 examination will not invariably enable us accurately to determine the 
 size or precise state of the heart, owing perhaps to the corpulency of the 
 individual, to intra-pulmonary conditions, to natural conformations of 
 the chest- walls, to organic or functional disease of one or more of the 
 abdominal viscera. When we are in reasonable doubt as to our diag- 
 nosis we should treat the case very much as we would if we were quite 
 confident we had to do with cardiac insufficiency depending solely on 
 organic heart disease. In fatty degeneration of the heart the cardiac 
 stimulants are often necessary in order to increase rhythmic action 
 through their influence on the intra-cardiac ganglia. Let us bear in 
 mind, however, two considerations, both of which have their value : First, 
 we can only help a fatty heart materially by stimulating its healthy 
 fibres. Now we should not do this to an excessive degree, because we 
 wish to save those which are degenerated from over-action, or increased 
 pressure from within the cardiac cavity, or else we run great risk of in- 
 creasing cardiac dilatation, or else producing rupture, it may be, which 
 would have a fatal result. In the second place, we are aware that it is 
 not merely the heart which is implicated in fatty cardiac degeneration, 
 the arteries are also affected with morbid alterations, usually of athero- 
 matous nature. These changes may also occasion bad consequences if 
 undue arterial tension is produced, as rupture in some of them — particu- 
 larly the cerebral ones — is not uncommon. 
 
 These objections may be considered by some as more theoretical than 
 practical, and as in no degree militating against the employment of 
 cardiac stimulants when their use for other reasons seems advisable. In 
 some cases of distended cardiac cavity through a vaso-inhibitory action 
 
54 ORGANIC DISEASE OF THE HEART. 
 
 upon the vessels, the arteries are somewhat distended. Digitalis by its 
 power over the peripheral circulation appears to restore these vessels to 
 their normal calibre, and hence its action under these conditions should 
 be regarded as really injurious. 
 
 In cases where the heart seems rapidly to fail, as it frequently does 
 where organic disease exists and an acute disease like pneumonia or 
 typhoid fever is grafted upon it, digitalis appears at times to have con- 
 siderable power in lowering the temperature and thus benefiting the 
 patient. Clinically, the lowering of the temperature as well as the 
 better condition of the patient seem to be accompanied by retained or 
 increased arterial tension. When the arterial tension fails, not only is 
 the condition of the patient, as a rule, unimproved, but the temperature 
 does not appreciably fall. Perhaps this action of digitalis may serve to 
 explain some remarkable effects occasionally obtained in the treatment 
 of pneumonia and typhoid fever, which without this explanation would 
 seem to be doubtful or mysterious. Of course, in considering such 
 action we should have in view the effect of heart stimulants, not merely 
 on one factor of cardiac power, but upon alb — many of which are com- 
 bined. 
 
 The heart, it is true, is a muscle, and upon this muscle digitalis, 
 strychnine, convallaria, caffein, etc., all act probably to a certain degree. 
 But the heart muscle is controlled by the regular rhythmic discharges 
 from its intrinsic ganglia, and these are probably even more effectively 
 stimulated to action in fevers or disease of microbic origin by the car- 
 diac stimulant than the muscle itself. 
 
 Belladonna is to-day often forgotten as to its beneficial action when- 
 ever neurosal difficulty is present in any condition of heart depression, 
 without regard to the precise organic disease which prevails. Not many 
 years ago belladonna was much lauded not merely for its valuable as- 
 sistance in helping all cases of chronic heart disease where arterial ten- 
 sion was low and the quantity of urine daily voided quite insufficient ; 
 it was also admitted to be a very powerful agent for the relief of the 
 effects of shock and when the patient was in a state of collapse which 
 threatened immediate death. Let us not forget, therefore, that, perhaps 
 in many instances where we fail to obtain relief from other drugs, 
 belladonna may afford us very valuable assistance. Fothergill insisted 
 in his work on heart diseases upon the use to which belladonna might be 
 referred, and, with what seems to be very clear insight, recommended it 
 highly. 
 
 Not infrequently I have had good reasons to believe that our ordinary 
 estimate of the value of belladonna is too low, and am convinced that 
 if it were more frequently prescribed in connection with strychnine we 
 should obtain very excellent results from it. In combination with iodide 
 of potassium, it certainly gives marked relief to many cases of aortic 
 
ORGANIC DISEASE OF THE HEART. 55 
 
 disease in which part at least of the pain is apparently connected with a 
 lack of synchronous rhythmic contractions between the two sides of the 
 heart, connected with an insufficient or badly co-ordinated nervous con- 
 trol. Possibly, its stimulating effect upon the nervous centres controlling 
 respiration may have also great value in the re-establishment of heart 
 power and more perfect rhythmic action. 
 
 Few authors have insisted upon the value of electric currents as a 
 means of restoring heart power. Reasoning from analogy, I am con- 
 fident that we neglect too much this means of relief. I have seen such 
 notable good effects both of faradic and galvanic currents in Graves' 
 disease; it has been of such evident and great use to patients in whom 
 the acute asthenia grafted on the previous cardiac changes was of immi- 
 nent gravity, that I feel as if I have often neglected a means that would 
 surely be helpful, if properly applied, when compensation is temporarily 
 lessened or gravely impaired. One pole should be placed in the region 
 of the neck, and the other over the cardiac region, and mild currents 
 should be daily applied for a limited time. I trust that others besides 
 myself will see the utility of electricity, and, it may be, obtain results 
 from it in the treatment of organic heart disease which have not hitherto 
 been secured. 
 
 The dyspnoea from which patients affected with chronic cardiac dis- 
 ease suffer, either continuously or spasmodically, is most distressing ; 
 sometimes it comes on in a sudden manner, perhaps in the middle of the 
 night, with or without a sufficient apparent accidental cause to produce 
 it. Frequently, however, these attacks follow imprudences in eating or 
 drinking. Indigestible, rich food taken late at night, and after any un- 
 usual nervous strain is a frequent cause of similar attacks in the begin- 
 ning of cardiac asthenia. During the attack the heart is unable to 
 expel its contents, and the right heart particularly seems to be specially 
 involved. The patients are anxious, distressed, panting for breath ; the 
 lips, face, and extremities are cyanosed ; the hands are cold and clammy ; 
 there is often free perspiration from the face and neck ; the pulse is 
 feeble and irregular ; they are often restless and uneasy and seek dif- 
 ferent postures to relieve their breathing ; sometimes they sit up straight ; 
 often they bend over on a chair or head-rest, and fix their arms and 
 shoulders so as to give them additional support, and thus enable them 
 to use the accessory muscles of respiration. The heart's action is inter- 
 fered with frequently by the bulging upward of the diaphragm, which 
 cannot descend in the abdominal cavity, owing to gaseous distention of 
 the stomach or colon. When the stomach is full of food and gas, nothing 
 gives more immediate relief, at times, than to have it emptied by an 
 attack of vomiting. On other occasions, the diffusible stimulants given 
 internally, i. e., alcohol, ammonia, chloric ether, in frequently repeated 
 doses, will be of almost immediate and great use. If the extremities 
 
56 ORGANIC DISEASE OF THE HEART. 
 
 are cold, hot-water bags or mustard poultices applied to them will help 
 restore the circulation. When the attack is severe and the position of 
 the patient imminently threatening, hypodermics of brandy, nitro- 
 glycerin, strychnine, or digitalis should be given and repeated several 
 times until the patient notably revives. The quantities of these drugs 
 which can be given to these patients with evident relief is often very 
 large. Of course, such attacks vary greatly as to their gravity, and in 
 some instances life itself hangs upon a thread. I have seen patients 
 more than once remain in a semi- collapsed condition several hours and 
 only revive thoroughly after I and others had expended all our efforts in 
 their behalf. 
 
 In dyspnoea of more chronic nature we find that pulmonary conges- 
 tion, bronchitis, cardiac dilatation or effusion into the pleural cavities are 
 frequent causes of it. Any of these thoracic complications may be ac- 
 companied also by a renal affection which renders the treatment more 
 difficult and the prognosis graver — sometimes the patient cannot lie down 
 at all for many nights. This position, often so painful to the patient, is 
 measurably relieved by a good bed-rest, with arms at the side to prevent 
 the patient's head or body from falling over or taking a position which 
 greatly increases the difficult breathing. Hypodermics of morphine 
 with atropine will sometimes quiet and subdue these attacks very 
 rapidly. When these drugs fail to relieve in appropriate doses, nitro- 
 glycerin is available and most reliable. This is particularly true if the 
 tension of the radial pulse is high and there is clearly present a state of 
 advanced arterio capillary fibrosis. 
 
 Whenever there is a moderate or large amount of fluid in one of the 
 pleural cavities, thoracentesis repeated one or more times gives great 
 relief to the breathing, and prolongs life many months in some instances. 
 Warm poultices, with the addition of mustard in moderate proportion to 
 the chest walls, is a very excellent means to give relief to distressed 
 breathing. Repeated applications of dry cups to the chest or over the 
 renal region are of great value. 
 
 As soon as the acute dyspnoea is relieved a free purgative dose with 
 calomel and compound jalap powder will carry off considerable fluid 
 from the economy, and thus afford sensible relief. Hoffman's anodyne 
 in full doses will often quiet extreme restlessness and promote sleep, be- 
 sides being of great service in lessening dyspnoea of functional character 
 and nervous origin, although connected with organic heart disease. If 
 there is much venous engorgement we can obtain more relief by blood- 
 letting than in any other way. Leeches, wet cups, venesection, may all 
 be used in certain cases with great advantage to the patient. 
 
 I have also known oxygen inhalation to be successfully employed. 
 Again, even when there is much bronchial engorgement, oxygen will 
 fail to produce any amelioration in the patient's condition. We are, 
 
ORGANIC DISEASE OF THE HEART. 67 
 
 indeed, compelled to abandon its use at times on account of increased 
 distress which it evidently occasions in the breathing. Inhalations of 
 nitrite of amyl, the internal use of the bromides and chloral are resorted 
 to by me with evident great resulting benefit in some instances. In the 
 use of chloral one must be guarded whenever there is danger of heart- 
 failure from organic cardiac disease, as the heart may suddenly be 
 arrested in diastole. Cardiac dyspnoea is frequently aggravated by an 
 underlying gouty condition, by hysteria, or emotional excitement, and 
 may be greatly relieved by appropriate medication addressed to these 
 diverse causative conditions. 
 
 The condition of the stomach and liver is also very important, and a 
 vomitive or purgative given at the proper time is able to afford much 
 relief, when otherwise the patient's distress would continue. It is wise 
 in many such cases to be cautious is rendering too grave a prognosis, as 
 the occasion does not 'always warrant it, and with judicious treatment 
 the patient may rapidly improve. 
 
ETIOLOGY AND TREATMENT OF CERTAIN KINDS 
 
 OF COUGH. 1 
 
 Cough is one of those symptoms we are called upon constantly to 
 treat. At times the diagnosis of its cause is relatively easy, and our 
 treatment satisfactory. It may last, it is true, for some days despite our 
 efforts to relieve, and during this time cause moderate annoyance, or 
 even considerable distress. Still, after a fair trial of remedies judiciously 
 employed, a measure of benefit is obtained, and both patient and physi- 
 cian are hopeful as to a speedy cure, and both are tolerably satisfied 
 with the amount of success accomplished in a given period. Again, 
 there are cases in which we know from the first that whatever treatment 
 may be followed the obstinate cough, in the nature of things, must per- 
 sist, and arrest, except from increasing doses of anodynes, can rarely be 
 effected. Such cases we are familiar with in certain forms of pulmonary 
 and laryngeal phthisis. 
 
 There are other kinds of cough which are also met with quite fre- 
 quently ; yet their diagnosis is made with difficulty, and their treatment 
 despite repeated changes, fails to accomplish much in the way of abate- 
 ment and cure. This is true not only of the patients who go first to the 
 family physician in search of help, but also of those who in the begin- 
 ning of their trouble gravitate toward some prominent specialist. 
 
 In the class of cases where the general practitioner is usually at fault 
 I would place the cough which is under dependence of an engorged 
 lingual tonsil. On at least two occasions I have treated wives of promi- 
 nent medical practitioners who were sufferers from annoying symptoms 
 of this origin, although previous to my seeing and treating them the 
 nature of the trouble had not been recognized. In these cases there was 
 no chest affection and no apparent throat trouble sufficient to cause the 
 distressing cough, or other symptoms. There was no evident local 
 disease elsewhere in one case ; in the other there were joint symptoms of 
 rheumatic gout. In one case the cough had resisted many usual reme- 
 dies given internally, and the repeated employment of sprays and 
 inhalation of balsamic vapors. 
 
 The cough in these cases is frequent, dry, paroxysmal. Anodynes, 
 even in moderately large doses, fails to afford relief. At times the cough 
 is occasioned by the sensation of a foreign body lodged at the base of 
 
 1 Read before the Climatological Association, June 14, 1895. 
 
ETIOLOGY AND TREATMENT OF COUGH. 59 
 
 the tongue, like a bristle, a bread crumb, or a bit of meat, but it is 
 impossible to dislodge anything or get rid of the annoying sensation. 
 
 Accompanying the cough there may be a continuous desire to swallow 
 constantly, and the effort of deglutition may be performed with some 
 difficulty. Indeed, I have had one case under my care in which the 
 difficulty of swallowing was so great as to excite much apprehension lest 
 choking should occur, and the young woman soon lost flesh and strength 
 to a marked degree, through dread of taking her meals. With the diffi- 
 culty of swallowing there may be a feeling of a constricting hand around 
 the throat, which occasionally seems as if it would throttle the patient. 
 This sensation is greatly increased when the patient lies down at night, 
 and, of course, increases his terror. 
 
 But these are very exaggerated cases, and frequently nothing betrays 
 the evidence of local irritation of the larynx from lymphoid hypertrophy 
 at the base of the tongue, except an almost continuous cough. I have 
 known such cases to be regarded for some time as phthisical, and again 
 as hysterical. 
 
 When the obstinate cough is thought to be evidence of incipient 
 phthisis, change of air, absence from business or household cares, cod- 
 liver oil, and creosote begins to loom up as the only remaining means of 
 helpfulness. If the patient be supposed to suffer from hysteria — and 
 how often is the so-called " globus hystericus " made to account for what 
 is caused by pressure from an offending mass — little or no treatment is 
 insisted upon. The patient is often spoken of as an imaginary sufferer, 
 for whom a cold douche, valerian pills, and some moral education sum 
 up about everything which can be done. 1 
 
 When these cases are examined with the laryngoscope, and it is only 
 with the laryngoscope that they can surely be made out, we note the 
 following conditions: The epiglottidean fossa, i. e., the fossa between 
 the epiglottis and the base of the tongue, is more or less completely filled 
 up and distended by a slightly irregular but rounded mass of lymphoid 
 tissue. This mass is sometimes deep red, sometimes pink, and again pale 
 in color. It is often covered with irregular cauliflower excrescences not 
 larger than a very small pea. Again, it is relatively smooth and 
 glistening like certain forms of enlarged faucial tonsils in children. The 
 mass may simply fill the fossa, pressing against the entire anterior sur- 
 face of the epiglottis ; or it may be so much larger on one side than it is 
 on the other that the pressure on the epiglottis is only partial, and on the 
 opposite side to the one where this is evident the fossa is not wholly filled 
 up. Frequently the free border of the epiglottis is, to a more or less 
 considerable extent, caught in or covered by the overtopping tonsillar 
 
 1 .1 am more inclined to the belief than ever that the nervous cough of adolescents described 
 graphically by the late Sir Andrew Clarke was simply a cough caused by an enlarged lingual 
 tonsil. 
 
60 ETIOLOGY AND TREATMENT OF COUGH. 
 
 mass ; and it would seem to be particularly this portion of the mass 
 which occasions the troublesome cough. When the patient phonates 
 the mass occasionally separates from the free margin of the epiglottis ; 
 occasionally it shows no separation at all, but adheres under vocal 
 efforts closely to it. 
 
 Frequently there are quite large veins distinctly defined on the ton- 
 sillar mass, and not seldom these veins will burst and allow more or less 
 blood to come into the mouth and be expectorated, which I have known 
 to cause the liveliest apprehension on the part of the physician and the 
 patient. Fortunately, the bleeding soon stops, and the patient is none 
 the worse for it, except mentally. 
 
 These enlargements of the lingual tonsil are uncommon among young 
 children ; they are also infrequent among young men and women ; but 
 toward middle life, in men and women, I have had numerous cases — 
 more among women than men. 
 
 The causes of the enlargement are certain menstrual derangements, 
 continued constipation, and an underlying rheumatic or gouty state. 
 No doubt, micro-organisms may infect as readily, perhaps even more 
 easily, this tonsillar mass than they do those masses at the faucial en- 
 trance. 
 
 In rare cases syphilis has doubtless localized itself in this region, either 
 causing marked hypersemia or a congestive condition, upon which a 
 mucous patch may readily develop, as it does upon the faucial tonsils. 
 
 How should we treat this engorged lingual tonsil ? Internally, we 
 must give the salicylates in fairly large doses, and usually we shall 
 obtain from their use very evident benefit. It is not essential in giving 
 the salicylates to be able to discover some other manifest rheumatic 
 symptoms; nor, indeed, should we feel compelled to obtain a clearly 
 rheumatic history. Despite the absence of either the one or the other, 
 we often get good results from this treatment. 
 
 In prescribing salicylic acid or the salicylates, it is very important to 
 get salicylic acid obtained from the proper chemical source. That 
 made directly from the oil of wintergreen is the only one which is safe 
 and judicious to use. The other is very apt to cause pain and nausea 
 or other symptoms of stomachal intolerance. While I believe sprays of 
 some benefit, especially those of carbolic acid combined with the essential 
 oils and boric acid, still these will not cure by themselves the lingual 
 hypertrophy. Local applications of a stronger kind are necessary. 
 Among these, I place foremost the galvano-cautery and compound tinc- 
 ture of iodine. 
 
 Excision of the tonsil by a specially devised knife or guillotine 
 (Chappell's) has been recommended highly by a few prominent throat 
 specialists, but thus far has not commanded general favor. The site of 
 the disease makes it awkward for operation with the guillotine unless it 
 
ETIOLOGY AND TREATMENT OF COUGH. 61 
 
 be imperatively required, and the risk from annoying bleeding, or some 
 other accident following excision, is not, in my judgment, as small as has 
 been affirmed. Formerly, I treated these cases with repeated applica- 
 tions of the galvano-cautery, and, upon the whole, my results were grati- 
 fying; still, owing to the soreness and swelling which lasted for several 
 days subsequent to the use of the cautery, I had reason occasionally to 
 be troubled in mind. 
 
 I do not remember to have had an abscess from the peritonsillar 
 structure after cauterization, but I know that several times the tonsil 
 was so much inflamed that I sought relief for my patient through re- 
 peated lancing with a curved knife. 1 The great objection, however, to 
 the use of the cautery in this region is the risk of burning the epiglottis, 
 and particularly its free border. Unless the patient is phlegmatic and 
 obedient, and holds himself very steadily, we may inadvertently pro- 
 duce an ugly sore which will give any amount of trouble before it heals. 
 
 Latterly, by repeated applications of compound tincture of iodine 
 to the tonsillar mass with a curved brush or sponge-holder, and by the 
 use of the salicylates internally, I have been able in a few weeks to 
 reduce these enlarged tonsils so that they ceased to occasion cough or 
 other symptoms of local distress. The applications of iodine may be 
 repeated daily with considerable advantage, or as frequently as can be 
 made without causing marked local soreness. Even when the cough 
 disappears, or the obstructed deglutition is no longer present, the voice 
 may be more or less hoarse and discordant for some time. 
 
 In using the galvano-cautery it must always be borne in mind that 
 an unfortunate burning of the margin of the epiglottis may bring on a 
 cough even more troublesome than the one we are trying to cure, and 
 for this reason, after considerable experience, I am inclined to reserve 
 its use for those cases in which internal treatment and the local use of 
 compound tincture of iodine remain without curative effect. 
 
 Another form of cough occurs in young children, and is often ignored, 
 or, if not ignored, the treatment is at least ineffectual, as it does not reach 
 the cause of it. Frequently children cough repeatedly, and at night 
 especially, on account of one of two conditions : either there is a dropping 
 of thick mucus, or muco-pus, from the nasopharynx upon or into the 
 larynx, or there is an irritation of the posterior turbinated bodies 
 brought on by local congestion. The first condition is made evident 
 frequently by the examination of the pharynx with an ordinary tongue 
 spatula. So soon as the tongue is moderately depressed the child has 
 an effort of gagging, and a large mass of mucus is seen between the free 
 border of the palate and the pharyngeal wall, squeezed downward by 
 
 1 1 have had two cases under my care in whom an abscess formed in this tonsil, and after 
 causing great distress, i. e.. dyspnoea and choking, burst spontaneously, to the great and imme- 
 diate relief of the patients. 
 
62 ETIOLOGY AND TREATMENT OF COUGH. 
 
 the forced effort which just precedes its appearance. Usually this con- 
 dition in children is due to more or less development of the pharyngeal 
 tonsil or lymphoid tissue at the vault of the pharynx. It can be cured 
 by a moderate scraping with the finger-nail of the right index-finger 
 introduced behind and above the soft palate. If the finger be properly 
 protected by a thick rubber nipple (i. e., such a one as is used to cover 
 the mouth of a nursing bottle) it will not be wounded by the child's 
 teeth. No anaesthesia is required. The pain from the scraping is very 
 slight, and the operation lasts but a few moments. To be thorough, two 
 or more scrapings should be made at the time, or if the child is very 
 restive after the first operation further interference may be delayed until 
 a later and more favorable occasion. In some of these cases there is 
 quite an amount of bleeding for a few moments during and immediately 
 after the operation ; but in my experience it has quickly ceased. If it 
 were to continue I would advise swabbing the post-nasal space with a 
 little of Mackenzie's tanno-gallic powder (three parts of tannin and one 
 part of gallic acid). Indeed, I have made this application on more 
 than one occasion as a simple matter of precaution, and with obviously 
 a satisfactory astringent effect. 
 
 In the event of the hemorrhage being at all abundant or continuing, 
 for any length of time, the proper thing to do would be to place a plug of 
 iodoform or sterilized gauze in the post-nasal space with the finger or a 
 pair of post-nasal forceps, allowing a string to remain attached, so that 
 the tampon could be removed at any moment it seemed advisable to 
 do so. 
 
 For a few days subsequent to the scraping it is wise to spray the nasal 
 and post-nasal passages with a mild antiseptic spray composed in part 
 of carbolic or boric acid. 
 
 Sometimes there is really no adenoid tissue in the post-nasal space to 
 account for the obstinate cough, and there is practically no hypersecre- 
 tion of mucus or muco-pus from this region. 
 
 The nasal passages may be either tolerably pervious, or they may be 
 notably occluded. Sometimes the occlusion is but little noticed in the 
 day-time, but at night it becomes greatly aggravated, and especially 
 when the patient is lying on his back, he is restless aud uncomfortable, 
 throws himself about the bed, coughs frequently, and yet apparently there 
 is not sufficient evidence in an ordinary inspection of the fauces and 
 pharynx to account for these morbid phenomena. 
 
 At times the cough is relieved very much for some time by a suitably 
 formulated nasal spray or a few applications of moderate severity to the 
 nasal mucous membrane. 
 
 I have found albolene with camphor and carbolic acid one of the best 
 combinations as a spray or vapor, and applications of carbolic acid and 
 glycerin (from 1 part to 8 to equal parts of each ingredient) as the most 
 
ETIOLOGY AND TREATMENT OF COUGH. 63 
 
 useful local application by means of a nasal carrier, I have hitherto 
 employed in these cases. 
 
 Whenever the cough is not altogether relieved by these means used in 
 the manner referred to, I find it is most useful to paint over the posterior 
 end of the turbinated bodies (as much as I am able;, and also the vault 
 of the pharynx, with carbolic acid and glycerin (1 part carbolic acid 
 to 6 or 8 parts of glycerin). In this way we are able surely to relieve 
 the congested condition which is so distressing, and no doubt, by dimin- 
 ishing the sensitiveness of the peripheral nerve filaments here distrib- 
 uted, to cure the reflex attacks of coughs which have proved so dis- 
 tressing. 
 
 It is most important, however, in just such instances to avoid over 
 loading the child's stomach at bed-time with heavy, rich, or, indeed, too 
 abundant food. A light supper, mainly composed of bread and milk, 
 with a little stewed fruit, is about all that such a child should be allowed 
 to take at its evening meal. If the liver be engorged from a too large 
 food supply, the result is temporary blocking of the circulation ; and 
 hence, in many cases, nasal obstruction and cough. Am I not borne out 
 in my statement when many of us acknowledge that certain cases of fre- 
 quent, obstinate nasal hemorrhage are only permanently arrested by a 
 rigid dietary and repeated counter-irritation, or depletion over the hepatic 
 region. 
 
 Just in the same way as a hyper- sensitive area may be discovered in 
 some portion of the nasal passages or nasopharyngeal space, so I find 
 occasionally sensitive areas in the pharynx, in the tonsillar region, upon 
 the soft palate, in the hyoid, or epiglottidean fossa, which will occasion 
 cough as soon as we touch the irritable point. 
 
 In what manner it is best to destroy these areas of cough is hard to 
 affirm absolutely. Sometimes I have found one agent, sometimes another, 
 relieve most. Nor is it always true that astringent or caustic applica- 
 tions will do better than soothing anodyne ones, or vice versa. 
 
 All local remedies at times remain futile, and cough persists and 
 annoys until an entire change of air and scene are obtained. 
 
 Of the internal remedies from which I have derived most benefit, I 
 would mention codeia and terpin hydrate. Codeia does not simply re- 
 lieve hyper-sensitiveness for a while, it is also directly curative ; more- 
 over, it does not constipate the bowels much, as a rule, or upset the 
 stomach, as morphine or opium almost invariably do. Terpin hydrate 
 may have, in addition to its well-known modifying action on diseased 
 mucous membrane, a mild antimicrobic power that perhaps is useful. 
 It always remains true that codeia in doses of gr. y 1 ^, more or less fre- 
 quently repeated, and terpin hydrate in tablet form of 1 or 2 grs. each, 
 every two or three hours, given internally, have been of great service 
 in my hands. 
 
64 ETIOLOGY AND TREATMENT OF COUGH. 
 
 I have not been able to determine invariably the cause of these sensi- 
 tive areas. I meet them occasionally in young girls of marked nervous 
 temperament, who are also ansemic and somewhat exhausted from too 
 much work, study, or pleasure. I also encounter them when the general 
 health is excellent, and it is impossible to get at a satisfactory cause. 
 
 Every practitioner is familiar, at least theoretically, with the fact that 
 paroxysmal cough may be occasioned by irritation in the auditory canal. 
 Most physicians have known the mere introduction of a probe or ear 
 speculum to be followed by an outbreak of cough, which only terminated 
 when the offending instrument was withdrawn. Sometimes the condi- 
 tion of the ear is such that we can readily account for cough produced 
 by examination, or, indeed, for the cough which previous to the aural 
 examination had remained a great mystery. Frequently, an impacted 
 mass of cerumen explains the cough, apparently, and after complete re- 
 moval of this substance the cough will speedily disappear. 
 
 There are numerous occasions, however, in which there is no 
 impacted cerumen and no symptoms of aural disease prior to direct 
 investigation by the physician. Then it is, and only then, that we first 
 discover that there is some impairment of the auditory function. But 
 what interests us particularly to state is that, one or more points of the 
 auditory canal are especially sensitive, and appear to have some connec- 
 tion with the appearance or continuance of the cough. In any event, 
 when the sensitiveness of the aural canal is diminished by suitable local 
 applications, the cough tends to diminish or disappear. The point most 
 frequently sensitive is that on the posterior inferior wall of the canal 
 very close to the membrane of the tympanum. Accompanying this 
 sensitiveness, there is pronounced redness of the surface of the canal, 
 with slight furfuraceous exfoliation of the cutaneous layer, which shows 
 distinctly inflammatory action. 
 
 Repeated applications of alcohol, or a mild solution of bichloride of 
 mercury (1-1000), or of nitrate of silver (1-100), will cure this condi- 
 tion after a time, as well as ameliorate, if not cure, the paroxysmal cough 
 from which the patient suffers. In many such cases, however, there is a 
 marked lithsemic condition, and we will help not only the condition of 
 the auditory canal, but also the secondary or concomitant congestion of 
 the pharynx and larynx by frequent doses internally of lithia and 
 bicarbonate of potash, together with some heart tonic like caffeine, which 
 is also useful in promoting urinary excretion. 
 
 Of course, in many cases like those of which I have been writing, the 
 aural inflammation and a catarrhal condition of the upper air-passages, 
 with marked increase of secretion, may exist together, and it is almost 
 impossible to say that the ear is in any sense the source of the cough, as 
 this symptom may be wholly caused by an independent laryngitis or 
 tracheitis which is present. 
 
ETIOLOGY AND TREATMENT OF COUGH. 66 
 
 In speaking on this subject of aural reflexes, it may be remarked with 
 a feeling akin to surprise how no attention is paid to it in late editions 
 of works on aural disease, like Politzer and Buck ; Dench, it is true, 
 speaks about the reflexes originating in the auditory canal, in his 
 chapter on impacted cerumen, but, so far as I could discover, nowhere 
 else; 1 and yet it is a matter of common knowledge, almost, that "ear 
 cough " exists. Despite this statement, I trust in a practical way my 
 reference to it in this paper may still be found suggestive and useful. 
 
 One of the most interesting facts connected with cough — originating 
 evidently in the upper air-passages — is how little we can judge, at times 
 of the source or nature of the cough from visible appearances ; some of 
 the worst-looking throats give, at times, literally no symptoms, and, for 
 one, I am disposed to regard these throats as usually, if not always, 
 normal. Symptoms are evidences of disordered function, and are appre- 
 ciated by our organs of sense and the reports given us by the patients 
 themselves. If, therefore, none can be found and none are accused, is 
 not this sufficient proof that the organ itself is probably healthy ? Again, 
 we shall have all the appearances of a healthy mucous membrane, and 
 yet, strange to say, the patient is always complaining of abnormal or 
 unpleasant sensations, or functional disability in the vocal muscles. 
 These statements are not always .exaggerated ; they are probably often 
 true, and, if rightly interpreted, lead us to a correct explanation and 
 treatment of them. 
 
 Many years ago I reported a case of chronic laryngitis, which served 
 to illustrate how the mucous membrane of the vocal cords may be in an 
 objectively morbid condition, though their physiological functions be re- 
 stored (The American Journal of the Medical Sciences, October, 
 1875). In an analogous way, I might also show at present how certain 
 patients affected with redness and swelling of the larynx cough a great 
 deal, and others do not. Of course, we can readily affirm that in the 
 one case there is some point of continuous irritation elsewhere which 
 causes constant cough, and in the other there is not. Such explanation 
 is, however, nothing more at times than a surmise, and we are thrown 
 back upon our inadequate knowledge at present to give a complete and 
 satisfactory solution of such examples. 
 
 In just such instances I have found the best curative effects in a 
 change of air and scene. I am not confident that it is of essential im- 
 portance that the change shall be from the city to the country, or to a 
 seaside resort. Sometimes the change from one city to another will rid 
 the patient of an obstinate cough which may have lasted for weeks and 
 resisted much and various medication. Frequently, however, I send 
 
 1 1 do not wish to mislead, so that I would add that Dench has a most excellent chapter on 
 " Aural Reflexes," but all due to disease elsewhere, and not in the canal itself. 
 
66 ETIOLOGY AND TREATMENT OF COUGH. 
 
 these patients inland to breathe the air of pine forests, and where the 
 soil is porous and well drained, and thus obtain most satisfactory- 
 results. I know, however, of one seashore resort, i. e., Atlantic City, 
 N. J., which even during the winter months has been most beneficial 
 to cases of " cough " which had resisted other remedial agencies. 
 The special value of this shore climate appears to consist, singular to 
 relate, in its relative dryness as compared with many other places on 
 the ocean. 
 
 In the early spring there is nothing which will remove a harassing 
 cough of this kind sooner than a few days' trout-fishing with rod and 
 reel. In the summer, when I am able, I like to send those who cough 
 obstinately to some good sulphur-spring, as I am satisfied that not only 
 the air in the vicinity of sulphur-springs, but also the sulphur-baths and 
 inhalations are very useful in building up impaired nervous constitutions 
 in which such coughs often predominate. 
 
 Alongside of these individuals there are others who are apparently in 
 good health and yet are constantly hawking, coughing, and expectorat- 
 ing. Usually these patients are lithsemic to an intense degree, and after 
 a while the lithsemic state is complicated by the presence of an elongated 
 palate and a thickened, congested pharynx and larynx. Lithsemia, if 
 continuously neglected, may become, or find expression in, an evident 
 rheumatic or gouty state. Under these circumstances it is not uncommon 
 to find the mucous membrane of the upper air-passages much infiltrated. 
 Frequently this extends far down the trachea, and tenacious mucus is 
 pretty constantly present and is expelled with difficulty. 
 
 Such a condition and the cough dependent upon it is helped more by 
 salicylate of soda or the salts of lithia than by local applications or 
 anodyne cough mixtures. I have already on a former occasion pointed 
 out the marked influence of malaria in producing congestive conditions 
 of the respiratory passages which occasion rebellious cough. This mani- 
 festation is often with difficulty traced to its cause, and medication alone 
 seems to establish the diagnosis. 
 
 In a few such cases it has seemed evident to me that quinine and 
 arsenic would not benefit, when bark, in tincture or fluid extract, fre- 
 quently repeated and in sufficient doses, was certainly curative. 1 
 
 The obstinate cough due to a dilated heart, or one affected at the 
 orifices with organic changes, is very frequent, and should be constantly 
 kept in mind. Not seldom, when I have not known what else to do, I 
 have freely stimulated a somewhat weak cardiac action and thus stopped 
 a bad cough in a few days. Previously the patient had taken numerous 
 
 1 In this connection I would remark that certain cases of pneumonia are evidently malarial 
 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. 
 
ETIOLOGY AND TREATMENT OF COUGH. 67 
 
 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. 
 
PROGNOSIS IN HEART DISEASE. 
 
 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 
 
PROGNOSIS IN HEART DISEASE. b'9 
 
 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 
 
70 PROGNOSIS IN HEART DISEASE. 
 
 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 
 
PROGNOSIS IN HEART* DISEASE. 71 
 
 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 
 
72 PROGNOSIS IN HEART DISEASE. 
 
 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 
 
PROGNOSIS IN HEART DISEASE. 73 
 
 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 
 
 6 
 
74 ' PROGNOSIS IN HEART DISEASE. 
 
 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,. 
 
PROGNOSIS IN HEART DISEASE. 75 
 
 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 
 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, 
 and originate structural changes ; they determine their character, 
 course, and issues ; in them is the secret of disease, and, if our control 
 of it is ever to become greater and better, it is upon them that our 
 experiments must be made." 1 
 
 Another form to which I would direct attention is that of the some- 
 what obese woman — married or unmarried — between forty and fifty 
 years of age. Not infrequently these women have a marked rheumatic 
 tendency. Not infrequently their urine on cooling deposits an excess 
 of urates of uric acid. They often have slight attacks of bronchitis, 
 ambulatory neuralgic pains, localized dry pleurisy. When in their 
 usual health they can take moderate exercise without great distress. 
 So soon as they have any acute ailment or depletion they suffer from 
 marked difficulty of breathing, a gone feeling at the epigastrium, and 
 an inward sense of suffocation, as they express it. Usually their cardiac 
 action is feeble, rapid, and slightly irregular under these circumstances. 
 Physical examination may or may not reveal at this time a soft blowing 
 murmur, systolic as a rule, often heard with greatest intensity in the 
 
 i British Medical Journal, August 16, 1884, p. 312. 
 
84 MINOR FORMS OF CARDIAC DILATATION. 
 
 mitral area, but also heard at times in the left intercostal spaces above 
 the nipple or at the lower end of the sternum. The blood may or may 
 not show a moderate degree of anaemia. Duriug and after their men- 
 strual epochs these patients are often at their worst, and whenever the 
 flow is abundant their condition inspires great solicitude. They do not 
 always have fever when they have their slight bronchitis or pleuritic 
 attacks. At other times the temperature rapidly goes to 102° or even 
 higher, and areas of local pulmonary congestion are accurately made 
 out. Such cases are amenable to judicious treatment, and in the course 
 of ten days or two weeks very great temporary improvement will take 
 place. I usually give very small repeated doses of nux vomica and 
 strophanthus in the beginning of these attacks. I insist upon rest in 
 bed and frequent small quantities of liquid or easily digested food. 
 Where there are cough and local signs of dry pleuritis a small fly- 
 blister, though painful, is a sovereign remedy. Of course, the men- 
 strual flow when excessive should be controlled with ergot or hot 
 douches. 
 
 In some of these cases where there is also well-marked anaemia there 
 is present at times and in a more or less continuous manner a small 
 amount of albumin in the urine. The clinical examination of the urine 
 is such that I have known patients of this sort to be told that they were 
 suffering from nephritis, and it was essential for them to live during a 
 long period upon a milk diet, and to reside in an equable, dry, and rela- 
 tively mild climate. In these cases the albumin would at times disap- 
 pear, but fatigue, indiscretions of food, temporary excitement would 
 apparently bring back the albuminuria. I have no doubt the kidneys 
 were affected with chronic congestion. I am also very confident that the 
 hypersemia was passive rather than active, and was, in reality and 
 mainly under the dependence of a weak heart, quite insufficient in its 
 action to keep up a proper vascular tension in the renal arteries. Here, 
 again, judicious cardiac treatment was essential at first. With the digi- 
 talis or strophanthus, however, I usually combine a small quantity of 
 nitroglycerin, as I deem it very important to dilate the peripheral cir- 
 culation and thus lessen the necessary work of the heart to become 
 effective. 
 
 There is another type of woman, and she is usually thin and nervous 
 about the time of the climateric or past it. The menstrual flow if it 
 still exists is slight. These patients may not be anaemic to any appre- 
 ciable extent. They have frequently very imperfect digestive assimila- 
 tion. They may have some dilatation of the stomach, and are frequently 
 nauseated and unable to take even the simplest forms of food for a time 
 without causing great and rapid gaseous distention, not only of the 
 stomach, but also of the bowels. The liver is inactive and the bowels 
 are torpid. We can give few medicines by the mouth except stomach- 
 
MINOR FORMS OF CARDIAC DILATATION. 85 
 
 ica and carminatives without making their condition worse. Although 
 their heart is extremely feeble, so much so at times in fact that we dread 
 almost to move or raise them to make a proper exploration of the chest, 
 yet if we so much as try to use any medication by the mouth to 
 strengthen heart action we shall almost surely bring on worse distress 
 and perhaps' excessive nausea and repeated vomiting. I have been 
 obliged to treat such a patient for days at a time with digitaline and 
 strychnine hypodermatically, while inhalations of oxygen were fre- 
 quently administered. Rectal alimentation with panopepton, pepton- 
 ized milk, egg, brandy, and a little opium at times took the place 
 almost entirely of feeding by the mouth for several days. Where the 
 repeated use of the hypodermatic syringe set up local irritation I was 
 obliged to incorporate my cardiac stimulants with very small rectal 
 enemata of water. Finally, after weeks of anxiety and constant nurs- 
 ing and unremitting attention, these women slowly regained their health 
 and strength, and the heart became sufficiently strong to satisfy ordi- 
 nary demands made upon it when the patient went about in a very 
 limited measure. The urine never, upon repeated examinations, showed 
 either albumin or sugar, but did show low specific gravity, deficient 
 elimination of urea, and perhaps a few hyaline or granular casts. I 
 could not positively affirm any general arterio-fibrosis. I could and 
 did strongly suspect its presence. The heart gave all the evidences of 
 slight dilatation of the ventricular cavities, but at no time was there 
 any manifest hypertrophy. In some patients there was rarely any 
 cardiac murmur, and all I could detect, as a rule, was great feebleness 
 of heart action without irregularity or intermissions. I have no doubt, 
 for my part, that if these hearts were examined post-mortem they would 
 show few or no changes other than those which follow. They would be 
 soft and flabby. They would not retain their rounded, globular form, 
 but would flatten on the table through partial collapse of the walls. 
 There would be no valvular changes. The orifices might be slightly 
 dilated. There would be, as stated already, slight enlargement of the 
 cavities and thinning of the muscular walls. The color of the heart 
 muscle would approximate that of the faded leaf; perhaps, usually it 
 would only be relatively pale and bloodless. The cavities would con- 
 tain small, imperfectly-formed post-mortem clots or liquid blood. Under 
 the microscope we should find the strise here and there imperfectly 
 marked. There would possibly be some well-marked granular degenera- 
 tion at times, and only very rarely the evidence of fatty degeneration. 
 If the latter existed it would more likely be in patches in the capillary 
 muscles, the septum, or the ventricular walls than generally diffused. 
 
 Unfortunately, these are at best clinical impressions rather than well- 
 ascertained facts. And why ? Simply because post-mortem examina- 
 tions of these cases are not made. The patients do not die, in my expe- 
 
86 MINOR FORMS OF CARDIAC DILATATION. 
 
 rience, at least outside of hospitals. In hospitals, when they die, they 
 have more advanced and graver phenomena of a similar condition, and 
 then it is we can surely and positively affirm what our findings are. 
 
 In many instances I have had a report from the pathologist which in 
 its main features was not unlike what I have attempted to describe. In 
 this connection I would refer to a paper of Dr. Danforth, of extreme 
 interest to me, read at the last meeting of this Association, on " Clinical 
 Forms of the Uric-acid Diathesis." It seems to me that some of Dr. 
 Danforth's cases may have been mainly instances of cardiac dilata- 
 tion, in which the renal manifestations were merely a resultant of a weak, 
 feeble heart action. At all events, I have portrayed the other side of a 
 clinical picture frequently encountered by myself. I do not wish to con- 
 vey the impression that I have made a new discovery — such cases as 
 mine are met with by all of you. They are also described more or less 
 perfectly in almost every text-book of cardiac disorders of the last fifty 
 years. Still I am free to confess that I do not know precisely where you 
 will find the clinical picture I have endeavored to delineate in quite 
 the same terms. 
 
 I may be asked whether I do not find these cases also among men. 
 Perhaps I do, but I do not recall them in such a vivid manner as to be 
 able to portray them. The laboring man, even though he may never 
 suffer from actual valvular disease, will undoubtedly have at times 
 marked cardiac dilatation. But usually there is more or less hyper- 
 trophy combined with it, and, even though the heart has become very 
 incompetent through structural weakness, there will be such considerable 
 enlargement that we feel confident that the autopsy will show more or 
 less thickening of heart walls. The same is true of old valvular disease 
 accompanied with cardiac enlargement. It is equally true, as a rule, 
 where the history shows that there has been a persistent and excessive 
 alcoholic habit. This is true also, although in less degree, of the busi- 
 ness or professional man affected with heart disease. 
 
 Extreme cases of heart dilatation and no hypertrophy are also met 
 with among men ; but the minor degrees, those to which I have referred 
 and tried to describe, are usually found among women. The intense 
 heart failure, coming on rapidly, almost suddenly at times among men,, 
 and unquestionably due to very great cardiac dilatation, against which 
 the heart is almost powerless to react, is sometimes seen after great 
 excesses. These cases, as we all know, may be rapidly or suddenly fatal 
 despite our most active means of resuscitation. Among these cases, 
 however, are unquestionably some in which the physical signs of cardiac 
 dilatation are impossible to determine accurately. I can, therefore, well 
 understand that their existence should be denied. In place of such a 
 diagnosis I cannot but substitute one of loss of nerve-power, either in 
 the intracardiac ganglia or in the trunks of the vagi. To admit this 
 
MINOR FORMS OF CARDIAC DILATATION. 87 
 
 would be perhaps also to acknowledge that the heart muscle was intact 
 and the cavities of normal dimensions. Such a belief would be strength- 
 ened by those instances in which certain cardiac tonics, and especially 
 digitalis, are of little apparent value, perhaps, indeed, directly injurious, 
 and rest in bed and suitable liquid diet with alcoholic stimulants appear 
 to be most useful. 
 
 Again, there are instances in which there is certainly no pronounced 
 structural kidney change, where we watch closely the sequence of clinical 
 phenomena. There is renal inadequacy only. The secretion of healthy 
 urine, viz., of normal color, density, in sufficient quantity aud without 
 abnormal constituents, after a few days or weeks of rest, and when the 
 patient is given easily assimilable food, returns, and our temporary fears 
 are allayed. In some cases I recognize a possible spasmodic condition 
 of the peripheral vessels and especially of the kidneys. We have inti- 
 mation of this by high pulse tension at times and the rapid good effects 
 of repeated small doses of nitroglycerin. Occasionally I have seen 
 cases in which the heart action was very feeble, without any accentua- 
 tion of the aortic second sound, and where the radial pulse itself had no 
 increased tension, and yet nitroglycerin was of undoubted service, for 
 after its use the heart's action was notably improved, and the secretion 
 of urine, from being almost colorless and even small in quantity took 
 on its normal appearance and character. No doubt the nitroglycerin 
 acted as a direct heart tonic to the cardiac muscle itself; no doubt, also, 
 it dilated the small vessels of the kidney, breaking up any spasmodic 
 condition that existed, and thus was of very great benefit to the patient. 
 At all events, I have certainly seen nervousness, marked twitching of 
 the muscles, apathy, and somnolence — all symptoms, as I believe, indi- 
 cating more or less so-called ursemic poisoning — disappear and the 
 patient progressively improve until fairly good health and strength 
 were established. Examples of this kind are not uncommon, I believe 
 as a resultant of what has appeared to be a grippal attack. 
 
 Through a contribution to the London Lancet in October, 1899, by 
 A. E. Sansom, I am of the opinion that he, also, has seen cases not dis- 
 similar. Cohnheim and Leyden have intimated that occasionally the 
 underlying cause of ursemic symptoms is found in cardiac insufficiency. 
 Hence the blood stagnates in the renal vessels. Clinical observations on 
 contracted kidneys support this view, as does the use of cardiac stimu- 
 lants for the relief of their manifestations. 
 
 From the point of view of prognosis the character of the pulse is 
 often very important. "When it is relatively weak and perhaps irregu- 
 lar the outlook becomes serious. Sir William Broadbent has pointed 
 out the gravity of a pulse of low tension when accompanied with symptoms 
 indicating possible cirrhosis of the kidney. I have frequently had 
 occasion to make a similar observation. No doubt many of these cases, 
 
88 MINOR FORMS OF CARDIAC DILATATION. 
 
 however, merely enter into the category of what Sir Andrew Clark has 
 described as " renal inadequacy " accompanied with some degree of cardiac 
 dilatation. These are a class of cases in which, although the kidney 
 presented no alteration of structure, it was unable to produce a per- 
 fectly healthy urine. In these cases the urine is low in density and 
 deficient in solid constituents, principally in urea and its congeners. 1 
 
 I might lengthen this paper considerably. I prefer not to do so, as I 
 very much desire a discussion from the members of the Association as to 
 its value and truth. 
 
 1 Albuminuria and Bright's Disease, by M. Tirard, London, 1899, p. 16. 
 
CLINICAL STUDY OF ACUTE MYOCARDITIS. 
 
 One of the most interesting and also difficult subjects connected with 
 cardiac pathology is that of inflammation of the muscular walls. 
 Formerly, as we know, the existence of this affection was denied, or, if 
 admitted by some authors, had relatively small importance as compared 
 with inflammation of the endocardium or pericardium. At a later date in 
 the history of cardiac disorders myocarditis commenced to assume some 
 importance. It is only, however, within a brief period that the different 
 affections of the muscular structure of the heart have received their true 
 value and consideration. I am glad to state at present that the 
 medical mind has had an awakening, and to those who are careful 
 observers and clinicians the mere presence of a murmur or a pericar- 
 dial friction-sound is no longer of great moment unless it carries with it 
 the probability that sooner or later real functional disability will occur 
 owing to its effects upon the adjacent muscular walls. Of course, the 
 effects of muscular changes must depend largely upon many conditions. 
 The causation is different ; the circumstances in which they occur are 
 manifold, and may be acute or chronic, limited or diffuse. 
 
 In acute diseases, especially those affecting the whole organism, and 
 mainly those of febrile type, we have to do with the most interesting 
 and most important cases, because our time is limited to act properly 
 and efficiently, and the threatening is often imminent, although the 
 indications may be obscure and our useful interference be questionable. 
 Mere doing is by no means so imperative as well doing. Life often 
 hangs in the balance, and immediately so. 
 
 In the eruptive fevers — in diphtheria, typhoid fever, pneumonia, rheu- 
 matism, in many septic conditions, in toxic states, and, above all, acute 
 alcoholism at times — how often do we stand at the bedside and ask, Is 
 this a case where the muscular fibre of the heart is already touched by 
 the poison of the disease to the degree where acute degeneration is 
 already present? Unquestionably there are times when the closest 
 observation and attention on our part will still leave us in great and 
 anxious doubt. Other instances present themselves in which we feel 
 that we are reasonably sure in our judgment and are quite confident 
 that no other diagnosis is sufficient or permissible to explain symp- 
 toms and signs satisfactorily unless it be inflamed or degenerated 
 cardiac muscle. 
 
 7 
 
90 ACUTE MYOCARDITIS. 
 
 In many instances of typhoid fever and diphtheria of marked viru- 
 lence and intensity in which the general symptoms have been alarming 
 almost from inception of the disease, in a very brief period, or about 
 the fourth, fifth, or sixth days, we occasionally remark a feeble and 
 very rapid heart action. The first sound may be low, distinct, muffled ; 
 the second sound may be somewhat accentuated and particularly over 
 the pulmonary area, or, again, this sound, although still distinct, lacks 
 force and normal intensity. With such a heart we have a rapid, feeble 
 pulse, small in volume, and easily depressible ; it may be unequal, 
 somewhat irregular ; a beat may now and then be lost or inappreciable 
 to our tactile sensations. Instead of a rapid heart we may have a slow 
 one ; but this is rare, almost exceptional in these acute cases. A soft, 
 blowing murmur at the apex and systolic in time is often developed. 
 It may be limited as to its area or it may be widely heard over the 
 prsecordia. While this is true, it is still heard most intensely near the 
 apex-beat or in the pulmonary area. In the latter case a pulsation of 
 the second and third left intercostal spaces may accompany it; and 
 this pulsation is of itself, as Russell has noted, an evidence of some 
 degree of heart failure. Restlessness, profuse perspiration, especially 
 of the face and upper limbs, accompany this condition. The patient is 
 apathetic, listless, soporose, or frequently there is a low, muttering de- 
 lirium from which he can be separated for a moment only by acquiring 
 his attention with forcible and loud questioning. With such a cardiac 
 state we may or may not have more or less implication of the bronchial 
 tubes or lung structure ; and dulness at the bases with fine crepitation 
 during inspiration and over an area of at least a hand's breadth is no 
 uncommon finding. The urine is apt to be somewhat deficient as to 
 quantity and to contain abundant urates, an occasional cast, hyaline or 
 granular, and a notable amount of albumin. 
 
 Cases like the foregoing, in diphtheria especially, are apt to terminate 
 fatally and often suddenly. This is also true of croupous pneumonia. 
 In typhoid fever they may go along about in the same way for several 
 days and then perhaps measurably improve. Such cases even in 
 typhoid fever are prone to be long and severe ones, and it is frequently 
 difficult to say positively what the ultimate outcome will be, even 
 though no other dangerous complication may subsequently arise. 
 
 What is the pathology of such a condition ? In the few rare in- 
 stances where I believe I have seen it at the autopsy, very little at 
 times that is positively indicative of muscular changes. It is true the 
 heart is soft and flabby ; it tears more easily than it should ; it is 
 darker in color, probably from blood-staining; heart clots are few, 
 badly formed, and usually cruoric in typhoid fever. 
 
 In pneumonia and diphtheria, on the contrary, they are often in 
 large part fibrinous, sometimes gelatinous-looking, sometimes with the 
 
ACUTE MYOCARDITIS. 91 
 
 fluid well pressed out of them, and almost appear to have several layers 
 of superimposed fibrin. Extensions of the clot are not uncommon in 
 the pulmonary artery, and they often fill moderately the right ventric- 
 ular cavity and auricle. The heart may be somewhat enlarged, but 
 where this is the case I have attributed it to previous disease. In a 
 similar way where there has been any very manifest valvular trouble 
 I could not believe that the acute trouble had anything to do with it. 
 
 I shall make an exception for a certain degree of vascularization of 
 the mitral valve which I have seen more than once. In diphtheria 
 notably there is often a decided beading, with redness, swelling, and in- 
 creased vascularity of its free margin. The other valves are usually 
 normal, at least to the naked eye. Under the microscope the cardiac 
 fibres present little or nothing abnormal ; here and there, perhaps, there 
 may be a slight granular condition, and the stria? may not be so distinct 
 as normal. 
 
 In those instances in which I have seen autopsies later on in the 
 course of acute disease of febrile type — and I am now speaking particu- 
 larly of typhoid fever, pneumonia, and diphtheria — I have occasionally 
 seen areas of the heart muscle either in the papillary muscles or in the 
 walls of the ventricles which seemed paler to the naked eye than the 
 rest of the heart. In these areas without doubt there was a deposit of 
 fat — microscopical sections have later revealed decided fatty degenera- 
 tion at least in limited areas ; and when that is the case not only the 
 nuclei of muscle may be much changed in form and structure, but 
 the heart fibres otherwise show the degeneration. The striation of some 
 fibres may have almost completely disappeared, the granulations may 
 be very numerous, interspersed with many fat globules, and the inter- 
 stitial cellular tissue between the primitive muscular bundles may be 
 notably increased, besides containing many red or white blood-cells. 
 
 I confess there is no direction in which this inflammatory and perhaps 
 degenerative development interests me more than in croupous pneu- 
 monia. The reason is not far to seek. In no other acute disease does 
 life terminate more frequently, suddenly, and at times unexpectedly 
 from so-called " heart failure " than it does here. Now what is this 
 due to unless it be through the myocardial inflammation or degenera- 
 tion which has become developed under the poison of the disease? And 
 this is proved particularly when we encounter those instances of very 
 limited or partial lung involvement, and yet they march steadily from 
 bad to worse despite our every effort made to save them. 
 
 Up to the present time we have no drug or system of medication 
 that is in any way satisfactory to meet these cases. The nearest approach 
 to it, in my judgment, is to respond to the indications in the following 
 manner : on the one hand, to help restore lowered nerve tone and 
 strengthen muscular activity with frequently repeated and even large 
 
92 ACUTE MYOCARDITIS. 
 
 doses of strychnine ; and, on the other, to destroy or neutralize the 
 pernicious effects of bacterial invasion of lung tissue, and thence the 
 blood and whole organism, with inhalations mainly antiseptic in char- 
 acter, of which I still believe beechwood creosote is the best, though 
 very imperfect, of which we have knowledge. I have not been able to 
 appreciate that the use of heart tonics like digitalis and strophantus, 
 in anything except small, repeated doses, and then only in a very tem- 
 porary manner, has proved to be really useful. Nor, indeed, with the 
 recognized pathology of the bad cases of pneumonia, diphtheria, or 
 typhoid fever do I see how they could be. 
 
 It always seems to me as though the great risk of producing such 
 forcible contraction of the relatively healthy fibres as to effect cardiac 
 dilatation through distention of those which are more or less degen- 
 erated neutralized all useful action. This is no mere baseless theory. 
 It is a conviction forced upon me by close, attentive clinical observa- 
 tion and inquiry. 
 
 I believe that the poisonous effects of these diseases, certainly so far 
 as the heart is concerned, in many instances, are more or less self- 
 limited. This being admitted, our effort should be to avoid, above all, 
 doing more or less irretrievable harm, and that, too, in a very rapid 
 manner. In many of these cases I am confident we do much less harm 
 when we guard our use of digitalis and strophanthus with nitroglycerin 
 or the nitrites. Thus we break up peripheral resistance as much as 
 may be, and so we lessen the necessity of the heart doing more work 
 than it can possibly perform. The diffusible stimulants are the medi- 
 cines which are most clearly indicated and many times urgently re- 
 quired. Alcohol, ammonia, ether, chloroform, camphor — all these are 
 good and at least rarely give us cause for regret. 
 
 There is one drug which I feel at present is far less used in these 
 acute cases than it should be, and that is iodide of potassium. Its effect 
 in stimulating the nerve centres, especially when the febrile stage has 
 lasted more than a few days, is perhaps known to a few, but is not yet 
 sufficiently insisted upon. Later, of course, and wherever other means 
 have failed us, and particularly wherever we dread the formation of 
 interstitial growth between cardiac fibres, already many good observers 
 acknowledge its value and rely upon its use more than any other drug. 
 
 With respect to oxygen, opinions are various. Some there are who, 
 despite frequent use of oxygen, affirm that it has little or no value. 
 Others there are who believe, and I am now more and more firmly fixed 
 in this opinion, that provided we give oxygen in its pure form, modified 
 only by a small proportion of nitrous monoxide, freely and more or less 
 continuously during the stress of the acute disease, we shall be able 
 frequently to ward off or prevent the calamitous effects of the bacterial 
 poison in effecting cardiac degeneration and notably that which is fatty. 
 
ACUTE MYOCARDITIS. 93 
 
 In addition to the foregoing I feel called upon to refer to the use of 
 cold in pneumonia only to speak of it in measured terms of praise. 
 While I have little doubt that in some instances a moderately cold 
 compress, properly applied around the chest, may be serviceable in re- 
 lieving pain, oppression, and lowering temperature, I do not believe 
 that we usually obtain the stimulating effects upon the cutaneous cir- 
 culation and toning up of the central nervous system which has been 
 ardently claimed for it. I am rather of the opinion that similar good 
 effects may be obtained from moderate warmth. 
 
 No doubt the old fashioned poultice of meal or flaxseed was dirty, 
 cumbersome, and unnecessarily troublesome to the patient and nurse ; 
 no doubt, also, by its frequent change it fatigued the patient often very 
 much, and yet it did soothe and relieve. We shall obtain these good 
 effects from lukewarm water covered with impermeable material, which 
 retains heat and moisture and without being a source of anything like 
 the same degree of annoyance. 
 
 I know these are heterodox views to many ; I know that the stimu- 
 lating effects of cold on the cutaneous circulation and central nervous 
 system are most ably advocated by a few, and in this connection I 
 should be derelict not to mention the name of Dr. Simon Baruch, who 
 has done so much to explain and to fortify those who hold to the great 
 advantages of cold externally and internally employed. 
 
 I must confess it always seems to me when a patient's nervous system 
 is already suffering intensely from profound systemic poisoning and 
 when degenerative processes are, without doubt, in a sure way of being 
 developed, that what we need especially is to soothe rather than to 
 stimulate, unless with our stimulation we afford the food that is most 
 readily disposed of as fuel ; and such, I take it, is essentially the role 
 of alcohol and the ethers in severe acute febrile disease. 
 
 Why is it when all other means fail do we almost invariably have 
 recourse to the soothing and stimulating effects of morphine hypoder- 
 matically, or, better still, sometimes small doses of extract of opium 
 internally? Here, again, I believe our useful interference must of 
 necessity be a very measured one. Pass by the narrow limit, and we do 
 irretrievable harm ; but no one can deny when a heart is weakened to 
 its utmost, when urinary secretion is very small and concentrated, that 
 many, many times such patients are marvellously relieved in every way 
 by the use of these drugs. I have repeatedly seen the heart beats 
 lessened in frequency and gain in strength and regularity. I have 
 also seen the urinary secretion become more abundant and resume all 
 its normal characters. 
 
 The question of the application of cold, of course, is often a relative 
 one ; but what I claim is that the application of a compress soaked and 
 wrung from water at 90° to 95° F. does just as much and more good 
 
94 ACUTE MYOCARDITIS. 
 
 than the compress applied from water at 65° or 70° F. Very soon 
 the compress will reach the former or even a higher temperature when 
 the body is at 103° to 104° F. or still higher, and surely the discomfort 
 and risks resulting from brief, temporary shocks to the nervous system 
 which frequently repeated cold compresses mean are not to be lightly 
 considered. 
 
 As to the cold bath in pneumonia, even the most enthusiastic of the 
 advocates of its use has abandoned it whenever an adult pneumonia 
 is treated (see Medical Record, August 4, 1900, article by Simon Baruch), 
 and finally reserves it solely for certain cases of pneumonia in children. 
 I am fully prepared to admit in this question of the utility of cold ap- 
 plications in pneumonia that here as everywhere in the practice of 
 medicine allowance must always be made for personal idiosyncrasy and 
 epidemic influence. There are a few patients who do bear cold appli- 
 cations apparently well, without much harm resulting, and occasionally 
 with seeming good effects. 
 
 There are also seasons in which pneumonias — despite seeming viru- 
 lence, it may be, at the start or in the initial stage — do not later show 
 at all the same virulence as we have seen at other times and under 
 seemingly like conditions. Why this is will not be satisfactorily under- 
 stood until susceptibility to disease and the intimate laws which govern 
 it are far better understood than they are by us today. 
 
 It must be always borne in mind in the care of these cases how essen- 
 tial it is to prevent as far as possible all exertion on the part of the 
 patient. The nurse should see to it that whenever a change of position 
 is desirable she should aid him as far as she can ; even the raising of 
 the head in the voluntary act of drinking should be assisted. An 
 alarming or fatal attack of syncope may possibly occur unless attention 
 be thus rigidly exercised. Frequently repeated and easily assimilable 
 nutrition should be kept up with beef peptonoids, milk, koumyss, broths, 
 egg-nog, etc. 
 
 In more than one instance I have felt assured that I have helped my 
 patient's condition markedly by giving an ounce or more of black coffee 
 by the mouth several times in twenty-four, hours, or a stimulating 
 enema of coffee per rectum in much larger quantity if there was evident 
 great prostration, sudden collapse, or pronounced stomachal intolerance. 
 
 Later on in the course of acute febrile diseases sudden death from 
 heart failure due to myocarditis is not very infrequent. I have known 
 it to occur in diphtheria when the outlook had appeared relatively 
 favorable and when the convalescent stage was almost reached. I 
 have also had at least one sad experience of it with a child recovering 
 apparently from typhoid fever. In many instances I have had little or 
 no doubt that owing to acute degeneration of cardiac muscular fibres 
 death occurred which might otherwise have been averted. 
 
ACUTE MYOCARDITIS. 95 
 
 In these cases there have been areas of the papillary muscles or of 
 the left or right ventricular walls where the yellow coloration, soft, 
 friable tissue and perhaps greasy feel gave to the naked eye positive 
 indications of what the microscope would surely reveal, viz., more or 
 less complete disappearance and fatty degeneration of muscular fibres. 
 
 It is reported by several reliable observers that they have found also 
 hyperplasia of connective tissue between the fibres, with numerous leu- 
 cocytes, red cells, and proliferative cells. Pigment granules, regularly 
 or irregularly disseminated within and between muscular fibres, have 
 been frequently observed. This change, especially as regards quantity, 
 is more apt to occur the older the patient is. The cells, both of muscle 
 fibre and cellular tissue, are much changed in form and structure or 
 may have disappeared altogether. It is also true that horizontal stria- 
 tum of muscle and the long fibrillation often no longer exist in parts. 
 The muscular fibre maybe almost hyaline in appearance and relatively 
 broad. It may be also atrophied and diminished in size owing to the 
 pressure and contraction exerted by connective tissue increase. The 
 latter change, however, is one much more frequently met with in 
 chronic myocarditis, where almost all changes, according to some writers, 
 partake of this character and make a real fibroid degeneration of the 
 cardiac muscle. 
 
 We should not expect to find fatty changes always widely dissem- 
 inated or deeply seated. Frequently these changes are merely in 
 patches, and elsewhere the cardiac fibre is apparently and relatively 
 healthy so far as the microscope reports. Even in the midst of a local 
 degeneration of tissue certain fibres are much more affected than others, 
 and alongside of one fibre which is almost wholly granular or fatty 
 another will be found nearly intact. 
 
 In those cases where there is accompanying endocarditis or pericar- 
 ditis the degeneration is apt to be much more diffuse than where no in- 
 flammatory condition of these membranes exists. The papillary muscles 
 and the ventricles, especially the left near the apex, are the parts usually 
 most degenerated. The auricles are very rarely at all notably involved. 
 
 In many of these cases, although the symptoms and signs during life 
 pointed with great certainty toward probable degeneration of muscular 
 cardiac fibre, we are surprised at the autopsy to find little or no evidence 
 of it. Beside, the valves and orifices are usually intact ; at least there 
 is no evidence of acute inflammation or old sclerotic changes. The 
 heart, however, is soft, flabby, has lost its shape, flattens out when rest- 
 ing on the table ; the walls are sometimes somewhat thinner than normal 
 and the cavities slightly increased in size. In such cases when the right 
 or left ventricle is opened at the apex and the hydrostatic test made the 
 valve is not competent. 
 
 Two facts are thus explained to my mind which have been recognized 
 
96 ACUTE MYOCARDITIS. 
 
 during life : first, functional disability ; second, a soft, blowing murmur, 
 heard at the apex during systole. All we can positively say of such 
 hearts is that they are really weakened by disease — that they have lost 
 their contractile power. Such hearts may have been primarily weak 
 organs, and just as they might not have been able to react properly to 
 any undue or excessive strain during health without showing the bad 
 effects of it, so during an attack of acute febrile disease they give way 
 rapidly both in function and structure. 
 
 Of course, to the pure anatomist or pathologist, who regards only 
 organic lesion as shown by eye and microscopical lens, to speak of func- 
 tional adynamia as something all important smacks too closely of mere 
 vague theory without proper and sufficient basis for intelligent argu- 
 ment ; but to others, and among these I find myself, there is just as 
 much cogency in the reasoning which admits a latent force or energy — 
 a vitality, in other words, which exists to a greater or less degree in 
 certain tissues of individuals and which is very defective in others — as 
 to attribute all symptoms and signs to appreciable local changes. 
 
 In any event, and for the while, we must count with such reasoning 
 and such facts ; and it is not the evidence of highest wisdom, to my mind 
 to ignore them. We are prone to explain these facts occasionally when 
 our every effort at accurate research, both as regards the tissues and 
 fluids of the economy, remains negative, by speaking of being run down, 
 under par, of poor nutrition, and using such catch terms as though 
 these words or expressions advanced our knowledge very materially or 
 were satisfactory in any final discussion. 
 
 In the malade imaginaire of Moliere there is a conference of the learned 
 doctors as to how and why opium causes sleep. The final conclusion 
 reached was "opium a le pouvoir dormitif" and that is all there is to it. 
 
 All saving agents, so to speak, whether regarded as food or medicines, 
 seem to me rationally what we should most keenly look for when called 
 upon to treat these cases. This is why agents such as tea, coffee, cocoa, 
 kola, etc., are so valuable when the body is submitted to a great strain 
 and where little or no other food or drink can be had. Take the sol- 
 diers of our army, the sailors of our navy, in time of war, on forced 
 marches or imprisoned in fortresses ; take men on the plains, or ex- 
 plorers iu the Arctic regions, or mountaineers who make high and 
 laborious ascensions — in any and all of these situations the universal 
 report is that in time of greatest need nothing will or can replace them. 
 Not only do they seemingly give almost as much if not more, at times, 
 of temporary energy and strength than alcohols or ethers, but their 
 power is far more enduring and beneficial when exposure or hardship 
 has to be for a long time resisted. 
 
 Physiologically they lessen the rapidity and degree of combustion in 
 the economy, the tissues are thus saved from any destructive action of 
 
ACUTE MYOCARDITIS. 97 
 
 phagocytic cells, and living force and energy are thus spared to their 
 utmost 
 
 I have attempted in giving black coffee frequently to my cases of 
 acute febrile disease, with evidences of heart weakness or cardiac degen- 
 eration, to meet the most evident indications up to the present time. I 
 have supplemented or varied the use of coffee at times both with cocoa 
 and kola. The former of these, particularly in the form of extract, 
 given by mouth or hypodermatically, has often helped me when I had 
 almost given up hope. I am inclined to believe that if my faith and 
 trust were greater, and I were to use these agents sooner and more freely, 
 I would get far better results in cases of acute myocardial degenera- 
 tion. One reason I believe that these agents do not always respond to 
 our hopes is because the preparation employed is relatively inert. Many 
 cocoa leaves, as many digitalis leaves, are dry and inert and of poor 
 quality when first gathered. I cannot place too much insistence upon 
 this. I have experimented with many preparations of cocoa as sold by 
 different druggists, and many are relatively inactive and worthless. 
 Too much care and inquiry cannot be taken in order to obtain a thor- 
 oughly reliable drug. And it is only too true that the power the best 
 of us have over the march, duration, and ultimate outcome of acute 
 disease is limited, and that this small power is reduced to a minimum 
 when we employ drugs which have little or no physiological action 
 when employed in the doses and forms which are wide-spread. 
 
 Hence, in part, the great skepticism so visible everywhere among our 
 best clinicians and practitioners of widest experience when they speak 
 of the curative action of drugs. There are, I freely admit, few truly 
 valuable ones among the vast mass of those that are advertised and sold, 
 and for this reason, also, it behooves us jealously to guard and protect 
 those that are from the meddling of ignorant, fraudulent persons. 
 
 In many cases of acute myocarditis the question arises as to whether 
 we have to do with concomitant endocarditis or pericarditis. In some 
 cases, indeed, it is undetermined for a time at least as to whether the 
 symptoms and signs present are not entirely due to the inflammation 
 of the endocardium or pericardium and the myocardium is little or 
 not at all involved in inflammatory or degenerative changes. 
 
 Endocarditis is not easily diagnosed at times ; it may be very 
 obscure. The local symptoms are often almost or entirely absent, with 
 the exception of the systolic murmur present over a limited or some- 
 what wide area of the prsecordia. There may be no localized pain or 
 marked discomfort ; no increased pulse or force in cardiac beats; no 
 irregularity or intermittency of cardiac contractions ; no abnormal pul- 
 sation in intercostal spaces ; no vascular distention in vessels of the 
 neck. The local expression of endocardial inflammation in slight de- 
 gree simply reduces itself to the murmur. It is true this murmur may 
 
98 ACUTE MYOCARDITIS. 
 
 be rougher, more intense, more metallic than the one proceeding from 
 mere dilatation of orifice without local change or from lack of close 
 coaptation of the velse due to lack of power in the heart muscle ; but, 
 as we know, the nature and intensity of a bruit is not of itself absolutely- 
 characteristic of inflammatory or other changes. Again, and this is 
 more frequently true, the murmur itself is absolutely similar to one that 
 we may fairly attribute to myocarditis alone. The pulse, of course, in 
 endocarditis may rapidly gain appreciably in force and frequency, but 
 this is usually true only when the inflammation of the endocardium is 
 considerable. There may be a sudden or rapid rise of temperature ; but 
 here, again, this means marked inflammatory changes of the endocar- 
 dium, and if accompanied by rigors or repeated chilly sensations there 
 will arise a reasonable suspicion as to whether there is not some septic 
 process present, such, indeed, as would lead to the ulcerative form of 
 endocarditis. If this be true usually the murmur has shown itself 
 rapidly and with much intensity, and its loudness very soon increases, 
 beside being accompanied with general phenomena quite different from 
 those of myocarditis, with tendency to cardiac weakness or failure. 
 
 I admit that much of the differential diagnosis is based upon proba- 
 bilities rather than upon certainties ; but this statement is no truer and 
 need be no more emphatic than in numerous other difficult positions in 
 the practice of medicine. Of course, the presence of a special form of 
 disease must always be considered. Other conditions being the same 
 I should look for endocarditis as being far more probable in acute 
 rheumatism than the other diseases already mentioned, simply because 
 we know that acute rheumatism has a particular predilection to attack 
 the endocardium. Even in rheumatic fever, however, I am now con- 
 vinced that we have rather exaggerated this tendency at times, and that 
 many instances of what is commonly affirmed to be endocarditis have 
 been without doubt mainly a myocardial inflammation or degeneration. 
 
 While I have not always been able to make the differential diagnosis 
 in the initial stage of the manifest cardiac determination, the march 
 of the disease and the nature and perhaps rapid or sure, though slower, 
 disappearance of the cardiac abnormal bruit have thoroughly convinced 
 me of the physical cause producing it. 
 
 If there be a pericardial inflammation the superficial character and 
 the nature of the friction-sounds may be sufficient to differentiate these 
 cases. Moreover, very soon the increased and special form of cardiac 
 dulness, the particular displacement of the apex-beat, the distant and 
 more muffled and duller apex- beats, with very possibly the almost entire 
 absence of these beats to inspection, and it may be palpation, help the 
 accuracy of our differential diagnosis very much. 
 
 I have not had occasion to see hearts at the autopsy table in cases of 
 influenza except where this disease had been complicated with pneu- 
 
ACUTE MYOCARDITIS. 99 
 
 monia, and then the hearts resemble somewhat those already described. 
 One marked difference, however, is in the contents of the cavities. In- 
 stead of the right ventricle and auricle and large vessels containing 
 fibrinous coagula, these were much softer, contained far less fibrin, and 
 were darker and far more cruoric, viz., contained a far larger number 
 of red blood-globules. I am quite confident, however, that the heart 
 of very many influenza patients is much affected. I have no doubt 
 that the nervous structures, ganglia, vagi, and sympathetic have lost 
 their tone and gone through certain changes. They may be recognizable 
 under the microscope on account of the cardiac and other symptoms 
 present during life. 
 
 Beside the nervous involvement there is also abundant evidence in 
 influenza that the muscle is attacked, and it is highly probable that the 
 great depression, continued weakness, syncopal attacks, slow recovery, 
 frequent returns of some of these symptoms subsequently and somewhat 
 periodically at times, are all due in part to myocardial changes. In no 
 disease with which I have a clinical experience is it more important to 
 guard patients against overexertion than influenza during its acute 
 and subsequent stages. 
 
 Patients who have been attacked severely with this disease may show 
 after a few weeks or months some cardiac enlargement due to dilatation 
 and evidently occasioned directly by the influenza attack. Not only, 
 therefore, during the period of the acute stage of this disease should we 
 be specially careful in not permitting any physical exertion — not even 
 the mere sitting posture in bed without assistance and support — but 
 we should for many weeks subsequent to an attack at all severe urge 
 upon patient and friends the absolute necessity of great prudence and 
 the strict avoidance of all intemperate or continuous bodily or mental 
 effort. Many hours of the twenty-four had better be passed in repose 
 or sleep and complete quiet mentally, and the recumbent posture 
 should be sought whenever the heart shows any signs of exhaustion. 
 Going up stairs, walking too rapidly, lifting heavy burdens, indulgence 
 at the table, use of tea, coffee, or tobacco, should all be strictly limited 
 for many weeks or months. Of course, there is the personal equation 
 here, as everywhere in medicine, and there are many patients who re- 
 cuperate rapidly even from an attack of influenza, and who on that 
 account need not, perhaps, exercise quite the same severe precautionary 
 measures as others. It is also true that the poison may be far less 
 virulent in certain instances than in others, and, therefore, we should 
 not expect the same severe effects to proceed from it. Nevertheless, it 
 is ever a safe rule to bear in mind how essential it is for the patient's 
 ultimate well-being to be careful in the convalescent period of in- 
 fluenza, typhoid fever, rheumatism, diphtheria, the eruptive fevers, and 
 pneumonia. 
 
100 ACUTE MYOCARDITIS. 
 
 I have seen many times in the convalescent stage of these diseases 
 the pulse remain unduly frequent for long periods of time, and I have 
 likewise seen this tachycardia show itself after very slight exertion, 
 when the patient otherwise seemed well and could scarcely be made to 
 appreciate the importance of considering this symptom, which pointed 
 clearly to weakness of the muscular walls of the heart. 
 
 Bradycardia may also be present, and the marked slowness of the 
 pulse, going down frequently to fifty pulsations or less, may be the 
 most important if not almost the sole evidence of impairment of cardiac 
 power. Surely too much emphasis cannot be placed on the judicious 
 valuation of this condition. If it be properly considered and wisely 
 treated not only will convalescence be in the end much shortened, but 
 all danger of subsequent probability of cardiac dilatation will be avoided 
 as far as may be. 
 
 It is manifest that in cases of moderate endocarditis or pericarditis, 
 during their acute stage especially, it is incumbent upon us to insist 
 upon absolute rest in bed in the recumbent posture (and even though 
 the type of dise'ase in which it occurs may be very mild in char- 
 acter) for many days or even weeks ; and yet, after all, I do not believe 
 the danger from overexertion in these affections is half so great when 
 they are unaccompanied with myocardial changes, nor do I believe 
 that, per se, they are so threatening to the future well-being of the 
 patient. 
 
 I do not deny that the facts to which I have referred are more or 
 less well known to the average good clinician and wise practitioner ; 
 still, I know in my own case it has taken many long years of practical 
 observation and experience, and the care of numerous patients, to thor- 
 oughly convince me of its very great interest and importance. Here is 
 where, unfortunately, the modern text-book of practice falls far short of 
 actual needs. Sayings similar in import to mine may be alluded to in 
 a line or two, but that is about all, and unless a man's own thought and 
 daily experience and observation serve to bring the facts constantly 
 before him he is prone to ignore or forget them. Even modern text- 
 books on cardiac disorders are apt to be far too brief, in my judgment, 
 in treating of the importance of rest in the treatment of acute disease. 
 
 Most people will swallow drugs, cover themselves with lotions and 
 liniments, be blistered or burnt, even go through a minor surgical oper- 
 ation, with far more equanimity and resignation than they will submit 
 to being put to bed and remain there for days or weeks unless they are 
 in great pain or are suffering from some marked disablement that they 
 can thoroughly appreciate. The practitioner has a difficult role many 
 times, especially during the convalescent period, in managing these 
 patients to their own advantage. 
 
 It is not always wisdom to explain to people about their ailments. 
 
ACUTE MYOCARDITIS. 101 
 
 They try to understand the doctor's position, and yet they do not. 
 They either exaggerate the gravity of their own case or ignore it far 
 too much. Whenever it is a question particularly of the heart, infinitely 
 more harm is sometimes done by showing accurately by explanation in 
 what the danger consists than in part to avoid explanation, or not to 
 speak at all, except to avoid making any categorical statement. This is, 
 of course, deplorable for many reasons. Truth is mighty and should 
 prevail, and an intelligent man or woman should claim the right to know 
 precisely what the matter is and what the physician really thinks of 
 their case. Just as soon, however, as the bald statement is made that 
 the heart structure is at all affected, then they proceed by vain im- 
 aginings to make themselves miserable for a long, long while to come. 
 It becomes almost impossible at times to disabuse their minds and make 
 life tolerable to them. They fret and worry, become introspective and 
 hypochondriacal, and lose snap and energy, which render their lives a 
 burden to themselves as well as to others. They are often the victims 
 of false dreads and foolish fears ; they imagine they cannot recover 
 and must always be, to a certain extent, invalids ; they harp on their 
 hearts, and they run from one physician to another to obtain expert 
 judgment. It would seem as though the minds of such could be dis- 
 abused, and that the earnest, convinced statement of their physician 
 that they would get all right in time if they are only careful and sen- 
 sible would be sufficient to quiet their fears and restore healthy mental 
 fibre ; but, alas ! in many cases this unhappily is not true. 
 
 I do not wish to be understood as upholding at all that this should 
 make the practitioner either untruthful or misleading, but I do mean 
 to say that it should make him very, very careful and circumspect as 
 to what he says. He must wholly gauge the disease he has to treat ; 
 he must, also, always consider the personality he has to do with ; and 
 singular it is that the very persons whom we might suppose are those 
 least likely to be demoralized by the truth if spoken fully and without 
 prevarication are, perhaps of all others, the ones to become most readily 
 discouraged and ultimately the most miserable unless with much 
 time, tact, and care they are absolutely convinced of the error in their 
 thoughts. 
 
 With respect to the other treatment of endocarditis or pericarditis, if 
 they be present, I would add that while I believe counter-irritation in 
 the form of iodine or blisters very useful frequently in shortening their 
 duration and intensity, I am not convinced that they would have much 
 value in the treatment of independent myocarditis of the sort I have 
 endeavored to study. 
 
 As to warm applications over the prsecordia, and, better still, hot 
 fomentations frequently repeated, and particularly where there is evident 
 cardiac weakness, these I believe are of really great value. They cer- 
 
102 ACUTE MYOCARDITIS. 
 
 tainly stimulate cardiac contractions to a very notable degree, and even 
 though there be considerable increase already in bodily temperature, I 
 recognize no strong objection to their use. 
 
 To my mind, the question of the amount of fever is often of secondary 
 importance, and in nearly all cases is but one of numerous symptoms 
 pointing to the intensity or gravity of the systemic poisoning. To com- 
 bat it rationally and without manifest detriment to other expressions of 
 disease may be all right, indeed probably is correct according to our 
 actual knowledge. To do more than this is many times obviously 
 uncalled for, and tends very much to produce harmful interference. 
 
 If the condition be already an adynamic one, where the bodily forces 
 are at a very low ebb and other forms of immediate and powerful 
 stimulation are required, I fail to see why transmitted heat, properly 
 applied, may not awaken and indeed partially restore wasted nerve force 
 very much more certainly than cold. To cite particular instances in 
 which this is true, even though not wholly analogous, would not be 
 difficult. 
 
 In any great shock to the nervous system following a blow or fall ; in 
 the complete nervous depression from loss of blood ; in the nervous 
 exhaustion caused by fright or imminent peril ; in the utter goneness 
 accompanying bodily privations due to lack of food or sleep, heat 
 locally applied over the heart, either as hot-water bag, hot compresses, 
 mustard poultices (where it is combined with the counter-irritant), 
 would be our first thought and usually prove most helpful ; and as the 
 body heat of an infective disease is in many particulars nothing very 
 different from the other appreciable expressions of lowered nerve tone, 
 why not make use of it promptly and efficiently ? ■ 
 
 As to the general treatment of endocarditis and pericarditis, I would 
 naturally incline to the use of the salicylates in moderate doses if acute 
 rheumatism were present ; but I should be more than doubtful of their 
 utility even in these instances where there were complications of the 
 other febrile conditions studied in this article. Certainly, I would not 
 give them where the nutrition was already at a low ebb or the stomach 
 had shown signs of intolerance. 
 
 During the convalescent period of acute myocarditis complicating 
 acute febrile diseases the indications for massage, resistant movements, 
 and saline carbonic baths, according to the Schott system employed 
 originally at Nauheim, seem pretty clearly defined. 
 
 It is to be borne in mind, however, that just as dyspnoea is often a 
 very marked symptom of myocarditis in its most acute stage, so later it 
 will frequently guide and direct us as to the efficacy of the move- 
 ments and baths and the duration of them. On its appearance in any 
 notable degree they should be stopped and only resumed with great 
 care and moderation. Harm results more frequently from doing too 
 
ACUTE MYOCARDITIS. 103 
 
 much at too early a period than through a judicious reserve as to both 
 of these considerations. 
 
 It is true that the Nauheim treatment employed at the spring?, or 
 artifically used elsewhere, may prove to be very beneficial in well- 
 selected cases, even though the heart fibres be degenerated. It is, 
 also, unquestionable that where the degeneration is far advanced and 
 the general nutrition has become much undermined by previous disease 
 or advancing years, it may work more than passing harm and become 
 of very little real value, but rather detrimental than the reverse. 
 
 Acute myocarditis may and does occur frequently among children 
 as a complication of their acute febrile diseases, and especially is 
 this to be remembered in scarlatina, whooping-cough, diphtheria, and 
 measles. 
 
 I am confident that this acute degeneration of heart muscle will 
 many times explain sudden failure of cardiac power when apparently 
 the patient is progressing favorably. I am also convinced that it 
 will explain the delayed convalescence of numerous cases in which this 
 complication would easily be disregarded or overlooked unless partic- 
 ular attention be directed to it. No doubt many instances of subse- 
 quent cardiac dilatation, with or without accompanying hypertrophy, 
 have been occasioned solely by inattention to or ignorance of this 
 muscular degeneration. 
 
 The very activity of children, their desire to play and romp and tire 
 themselves with their games and contests, is an additional reason why 
 special care should be exercised so as to ward off an unfortunate sequela 
 which may be otherwise lasting and troublesome. I have not infre- 
 quently met with cases which, as I interpret them at present, may trace 
 their later cardiac inadequacy to the influence of diseases of early 
 childhood. 
 
 I do not believe, in my experience, that the acute myocarditis of chil- 
 dren differs very materially, so far as symptoms go, from the same dis- 
 ease in adults. The ultimate prognosis, however, it seems to me, is less 
 serious, simply because the nutrition of the child being usually more 
 active his cell elements are re-established sooner and more surely, and 
 hence the untoward, far-reaching effects of cardiac weakness are less 
 likely to become manifest. 
 
CHRONIC MYOCARDITIS AND FATTY DEGENERA- 
 TION OF THE HEART. 
 
 OLiNicALLy these two expressions of cardiac degeneration are fre- 
 quently most difficult to differentiate accurately. We have our sus- 
 picions based upon a fair interpretation of the case as a whole, and 
 sometimes the results of the autopsy justify our probable diagnosis. 
 Many times we believe we shall find not merely fibroid changes or, 
 indeed, simple fatty degeneration, but there will be a combination of 
 both changes. In the advanced forms of fatty change particularly, 
 and whenever we have in the history of the patient efficient causation 
 of such alteration, our belief in its existence is very positive. There 
 are, however, numerous instances in which our diagnosis during life is 
 at best very problematical, and yet it seems to me any other diagnosis 
 at what we observe falls short of seeming truth, and is at best somewhat 
 unsatisfactory to the practitioner. While we know, for example, in 
 the graver forms of ansemia, and notably in the so-called pernicious 
 form, fatty degeneration of heart muscle is no uncommon finding, I do 
 not believe that physicians are apt to consider that the heart may be 
 structurally affected in the simpler forms. 
 
 It is true that many symptoms point to cardiac weakness. Notably 
 we would put emphasis on lowness of the heart sounds at times, on 
 extreme rapidity of its beats, with sensations of fluttering and cardiac 
 distress. Sometimes there is a systolic murmur which covers in part 
 or wholly the normal sound. Frequently this is absent. Attacks of 
 dizziness or faintness may come on readily and repeat themselves with 
 little or no sufficient cause. I have seen such an attack where the 
 patient was unconscious for a period of half an hour or more. During 
 this period the pulse was very faint, sometimes almost imperceptible at 
 the wrist. There was occasionally a lapse of pulsations at the wrist 
 for one or two cardiac beats, accompanied with marked irregularity. 
 The extremities were cold, the respiration shallow and suspicious. 
 After such attacks and when the patient's strength had partially 
 returned there was no enlargement of the heart which could be discov- 
 ered, no abnormal pulsations either on the chest or in the neck, and 
 no venous hum in the jugulars. 
 
CHRONIC MYOCARDITIS. 105 
 
 I am of the opinion to-day that such cases often mean heginning 
 cardiac degeneration of the fatty type, and that any other interpreta- 
 tion inadequately expresses the best medical judgment. Of course, they 
 require iron and arsenic to re-establish the blood condition. They are 
 also temporarily benefited at times by the use of intestinal antiseptics; 
 still, in order to bridge over the acute attacks we must give cardiac 
 stimulants freely and repeatedly and aid with the heart tonics of 
 strophanthus and strychnine judiciously administered. Oxygen also 
 given systematically is of great help and must be insisted upon. 
 
 We all feel we know the usual gouty heart fairly well, viz., the heart 
 affected with moderate hypertrophy of the left ventricle and adjoined 
 to evidences of more or less fibroid changes in the kidney and general 
 arterio-capillary circulation. Whenever this hypertrophy is no longer 
 thoroughly compensatory and evidences of heart weakness develop, as 
 shown by local and general signs and symptoms, we are frequently 
 brought to the position of asking ourselves whether cardiac degenera- 
 tion be present, and if so, its extent, variety, and nature. 
 
 Our diagnosis must be determined by several considerations inde- 
 pendently, perhaps of the underlying and evident gouty changes. It 
 may be that the patient has been a free liver, is of corpulent frame, and 
 has indulged more or less and for a considerable time in the use of 
 alcoholic stimulants. 
 
 These conditions would tend to make us reasonably sure of the 
 presence of some fatty degeneration of muscular fibre. The condition 
 also of the liver, notably where it is torpid and enlarged and there is 
 possibly some additional abdominal enlargement with tension of the 
 parietes, would make us suspect cirrhotic and fatty changes in this 
 organ. The presence of ascites may remain doubtful for weeks and 
 months, and never, indeed, be accurately determined. Again, in a 
 relatively short period succussion and palpation may unquestionably 
 reveal abdominal effusion in small or moderate quantity. In these 
 instances the pulse may never have increased tension, or only to such 
 slight degree that our tactile sensations, or even the use of the sphyg- 
 mograph, may not corroborate our suspicions, but simply leave us in 
 reasonable doubt. Here, again, it is the skilful touch, the keen appre- 
 ciation of local changes which proceeds from long, careful experience, 
 or the expert and, may be, repeated use of the sphygmograph which 
 shall solve our difficulty. In any event, but particularly where our 
 findings are positive, we believe that we shall detect an excess of fibroid 
 tissue in the heart in certain spots between atrophied, compressed, or 
 degenerated fibres. 
 
 The cerebral symptoms, which may be passing or more or less per- 
 manent, while pointing to cardiac degeneration, do not tell us positively 
 whether the fibroid changes or fatty ones are predominant. If the 
 
106 CHRONIC MYOCARDITIS. 
 
 mental activity of the patient has failed slowly and evidently for many 
 months, if the memory be impaired, somnolence increasing, and even 
 slight mental exertion be accompanied by geeat fatigue, slowness, and 
 difficulty of speech and obvious lethargy, we are inclined to the opinion 
 of marked fatty degeneration, always supposing the other signs and 
 symptoms mentioned are present. If now the arterial tension remains 
 high the coats are visibly thickened, knotty, tortuous, giving proof of 
 decided atheromatous changes, we are prone to believe that the intra- 
 cardiac condition will be more likely that of chronic myocarditis, 
 with marked fibroid changes. Any calcification of the arteries, as 
 of the radial or temporal, will only accentuate and confirm this judg- 
 ment. 
 
 This condition we should not find except in very rare instances,, 
 unless the patient were one already of advanced years or the gouty 
 dyscrasia were intense and of hereditary origin increased by bad habits 
 of life, speaking mainly from the hygienic stand-point. 
 
 In some instances we are led to believe that on autopsy we should 
 find the coronary arteries notably affected. These examples are espe- 
 cially those in which prsecordial pain and anxiety had been evident at 
 times and with moderate or great intensity. 
 
 I saw a patient, not long ago, a professional man, about fifty-five 
 years old, who gave the following history : He had been a careful 
 liver so far as food and alcohol were concerned, but had for many 
 years smoked immoderately and kept late and irregular hours. He had 
 done much hard work in active professional life and in a literary way. 
 He had for many years been a chronic dyspeptic, showing itself by 
 slowness and impairment of digestion, belchiDg of wind, and capricious 
 appetite. He had never suffered from symptoms of heart weakness or 
 distress. Calling to see him, I found him pacing the floor, with marked 
 dyspnoea, prsecordial distress and great mental anxiety, and the feeling 
 of impending disaster. The hands were cold and the face blanched ; 
 the pulse was regular and tolerably full ; the radial arteries were thick- 
 ened and there was apparently increased tension ; the heart was en- 
 larged, showing hypertrophous dilatation, moderate in amount. This 
 attack had lasted twelve hours, without relief spontaneously, and was 
 increasing in intensity, as shown by the augmented distress. The 
 swallowing of numerous soda-mint tablets, which frequently gave relief 
 to simple dyspeptic conditions, were of no avail. 
 
 I prescribed immediately a heart tablet of strophantus, digitalis, 
 atropine, and nitroglycerin, and in a few hours there was great relief. 
 The urine during the attack was high-colored and concentrated, but 
 contained neither albumin nor sugar. In a few days he was about as 
 usual. I advised repose from work and careful dietary, with the use 
 of cardiac stimulation if required. In a short while he was better than 
 he had been in many months and had had no recurrence of his angi- 
 nose symptoms. 
 
 No doubt, to my mind, this patient has intracardiac changes, probably 
 of the fibroid type. It is probable also that this coronary circulation is 
 
CHRONIC MYOCARDITIS. 107 
 
 defective and that endarteritis is present. Did he have some temporary 
 and incomplete obstruction of one or other of these arterial branches at 
 the time of his attack? This, I believe, although I cannot affirm it. I 
 only know that the other diagnosis is sufficient to explain his symptoms 
 satisfactorily. Probably the causes enumerated were all more or less 
 contributory to the development of the attack. Judging by the 
 sequence of events, I believe that nervous tone to the heart was 
 partially restored by relative rest from work and that the stomachal 
 condition was improved by appropriate dietary. The use of the cardiac 
 tablets during the attack certainly gave marked relief and possibly 
 prevented a fatal termination due to complete clogging of one or both 
 main arterial coronary branches. 
 
 I have known of the case of another professional man, about fifty 
 years of age, whose habits were not different from those of many toler- 
 ably successful ones at this period residing in a large city. He worked 
 moderately but not unduly ; he ate and drank with proper selection 
 and due regard for his habits and peculiarities ; he gave himself a fair 
 amount of recreation, took long summer vacations, and was fond of the 
 water and yachting. At times he had very slight attacks of dyspnoea 
 and praecordial anxiety, which never meant absolute pain or great dis- 
 tress ; indeed, these mild attacks occurred at infrequent intervals and 
 disappeared spontaneously and in a few minutes or hours at most. One 
 afternoon, hastening home from his boat on the river to dine and meet 
 his wife, who was anxiously awaiting him, as he was late, he had an 
 attack of severe angina pectoris and died suddenly in the street. 
 
 The following description of the cardiac changes found at the autopsy 
 is copied textually from notes kindly given me by the pathologist : 
 
 Moderate degree of hypertrophy of left ventricle. Valves compe- 
 tent. Atheroma in mitral valve and in beginning of aorta. In latter 
 situation this is most abundant about origin of coronary arteries, whose 
 lumen is distinctly encroached upon by it. On opening of coronary 
 arteries atheroma is found in their walls extensively beyond their origin. 
 In this way their calibre is considerably narrowed. Microscopical 
 examination of heart muscle reveals increase in pigment in cells about 
 nuclei and a slightly granular condition of muscle cells generally, but 
 no distinct fat. There is no obscuration of transverse strise, and there 
 is no increase in fibrous tissue. 1 
 
 Analogous instances to this are not infrequently met with. Of 
 course, the precise nature and the degree or intensity of the signs and 
 symptoms experienced during life vary greatly. In a similar manner 
 the rapidity or suddenness of the fatal termination, if it occur, varies 
 also very much. Whenever the coronary circulation is immediately and 
 wholly obstructed sudden death takes place and one of several findings 
 
 1 The findings at autopsy are here unusual, in that there was no occluding thrombus and 
 the muscle changes are slight. 
 
108 CHRONIC MYOCARDITIS. 
 
 is evident at the autopsy. It may be that the coronary artery is filled 
 up with an embolic plug, which has its origin in the heart either from a 
 cardiac thrombus or from a detached portion of vegetation from a dis- 
 eased valve or cusp of the mitral or aorta. In such cases the coronary 
 arteries may be relatively free of disease, although frequently there 
 may be even here a concomitant condition showing local degeneration, 
 though slight in amount. Wherever — and this occurrence is much 
 more usual — the coronary arteries themselves are more diseased, show- 
 ing inflammation, thickening — endarteritis, in other words — or pro- 
 nounced atheroma, with possible calcification at certain points, they 
 are occlued with a thrombus. 
 
 The arteries may be occasionally affected and narrowed mainly or 
 entirly at their orifices, or what is truer, ordinarily, the coronary 
 arteries are thickened, tortuous, atheromatous, or calcified throughout 
 the larger portion of their distribution. These changes have, of 
 course, greatly decreased their lumen or the extent of their calibre 
 internally, so that the heart has been imperfectly nourished by an 
 insufficient blood supply for a long period, and at a given moment a 
 thrombus forms locally and almost inevitably, and a fatal result ensues, 
 although, of course, in a somewhat less rapid manner than if an em- 
 bolus has been the immediate and efficient cause of death. 
 
 The local changes of the heart muscle in these latter cases particu- 
 larly partake of a fatty or fibroid character and are more or less local- 
 ized or disseminated in their distribution, according to modifying gen- 
 eral conditions. Moreover, the time during which the changes have 
 taken place and the age of the patient have much to do with the 
 character of these changes. As I have already pointed out, it is 
 almost impossible prior to death and direct examination of the heart 
 to state positively just what shall be found, so far as the precise changes 
 or the limitations of the morbid involvement of the coronary arteries 
 and heart muscle are concerned. 
 
 In old valvular troubles of the heart, whether they be of the nature 
 of stenosis or regurgitation, in chronic pericarditis where the adhesions 
 are tough and fibrous, in an advanced condition of hypertrophy of the 
 heart, with probably much cardiac dilatation, fatty degeneration is 
 almost surely going to occur at a given time, provided the patient's 
 life is sufficiently prolonged; then, of course, notable cardiac weak- 
 ness, prsecordial distress and dyspnoea, cyanosis, infiltration of the lower 
 limbs, weak, unequal and irregular pulse, deficient and concentrated 
 urinary secretion, are some of the numerous painful phenomena with 
 which we are all familiar. 
 
 In these cases we naturally expect and usually find post-mortem far 
 more disseminated degenerative changes of the heart muscle than we 
 do in the instances previously cited. As a rule, the left ventricle, and 
 
CHRONIC MYOCARDITIS. 109 
 
 more particularly the portion of it near the septum, is specially affected. 
 The columns carnese — the papillary muscles — are frequently reduced 
 in size, changed in color, soft to the touch, possibly giving a greasy 
 feel, easily torn or lacerated, and showing to the naked eye indubitable 
 evidences of fatty degeneration which microscopical investigation will 
 merely serve to reaffirm. 
 
 The right ventricle may also be degenerated in parts, although less 
 frequently, and it is now known that the auricles are sometimes in a 
 certain degree degenerated, although this statement was formerly 
 denied. 
 
 If there be chronic myocarditis present, which occasionally occurs, 
 the heart muscle is hard and resistant in spots and very often dimin- 
 ished in thickness where this exists, owing to the deposit of fibrous 
 tissue which has practically caused many muscular fibres to atrophy, 
 degenerate, or almost or completely to disappear. 
 
 In those corpulent people who have accumulated flesh continuously, 
 slowly, and in large amount, the heart is no exception to the great 
 number of viscera which become more or less involved. The deposit 
 of fat upon and around the heart usually seeks at first those regions 
 where fat is deposited to some extent normally, and particularly in the 
 grooves between the auricles and ventricles and along and over the 
 intraventricular septum. Later, it is no uncommon finding to discover 
 fat under the epicardium or the endocardium. Whenever this occurs 
 the fatty infiltration has extended deeply into the heart muscle and 
 between the muscular fibres to such an extent that the force of the 
 heart-beats is notably lessened, and many of the phenomena which 
 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. 
 
 The primary fibres are occasionally almost homogeneous in appear- 
 ance. Alongside of fibres much atrophied or degenerated there may 
 be others relatively healthy. 
 
 In chronic fatty degeneration of the heart muscle, especially if it is at 
 
118 CHRONIC MYOCARDITIS. 
 
 all advanced as to its stage, the color of the muscle is notably pale and 
 yellow in places. Sometimes, however, where the changes are not so 
 far advanced, at least in spots, but more generally disseminated, the 
 heart muscle, particularly of the ventricles where the degeneration is 
 most pronounced, is less changed in color from the normal. However, 
 in these instances the muscle has lost its consistence, is very flabby, 
 and the heart flattens out and loses somewhat its healthy outline on 
 the table ; beside it has lost resistance and is easily torn and lacerated. 
 Under the microscope the diseased fibres may show very numerous 
 granules, or at an ulterior stage these granules may be replaced by many 
 glistening, shiny, very refringent round bodies of large calibre, which 
 evidently are oily or fatty. Here, again, the nucleus of the muscle may 
 or may not have become degenerated or have disappeared entirely. 
 The same is true of the lateral strise and the longitudinal fibrillations. 
 
 There may sometimes be an overgrowth of pigment granules. These 
 granules may be deposited in the muscular fibre itself or in the inter- 
 stitial connective tissue between the fibres. The pigmentary granules 
 may be more or less irregularly placed. Usually there are a larger 
 number near the muscle nucleus. Occasionally the whole fibre may 
 be larger than normal and appear almost entirely homogeneous. 
 
 Alongside of some fibres completely degenerated there are others which 
 are relatively healthy or diseased only in parts. The connective tissue 
 between the fibres in typical fatty degeneration of the muscle is usually 
 not much, if at all, increased in quantity. In other cases, especially 
 where there are fibroid changes throughout the vascular system and in 
 different viscera, there may be a considerable increase of interstitial 
 connective tissue and pronounced fatty degeneration. 
 
 For further and more complete and accurate knowledge of the 
 pathology of these cases I would direct my readers to the best modern 
 treatises on cardiac disorders, among which that of Gibson seems to 
 me particularly valuable. To this author I feel especially indebted 
 for much valuable knowledge, which I have not hesitated to utilize 
 and to whom I now give full credit. 
 
ANGINA PECTORIS. 
 
 Angina pectoris, in its typical form, is in my experience a very 
 rare disease. Pseudo-angina, or what resembles it at times, cardiac 
 asthma, is not infrequent. Although angina pectoris is described 
 among the neuroses of the heart by authors, this view in my judgment 
 is frequently erroneous. In the great majority of instances where 
 angina is present there exist also organic changes of the coronary cir- 
 culation, of the cardiac muscular fibres, or a lesion of the aortic orifices. 
 
 I should be loath to admit, except in a very exceptional way, the 
 existence of true angina purely of neurotic origin. On the other hand, 
 pseudo-angina is very frequently of this provenance, accompanied by 
 symptoms of flatulent dyspepsia. It must be understood, however, 
 that there are cases on the border-line in which, during life, we have 
 great difficulty in pronouncing as to what symptoms are of nervous 
 origin and what are clearly due to organic changes of the heart or 
 arteries. 
 
 In many such instances, unfortunately, even if death occurs, we are 
 uot always able to obtain verification of clinical facts by the results of 
 an autopsy. Hence, certain theories are brought to the front which 
 have no basis in actual, reliable observations from the dead-house. 
 
 One statement is certainly true of angina, viz. : that it has usually 
 connected with it an element of spasm or sudden intracardiac pressure 
 which separates it notably from conditions which, in many ways, are 
 similar, and yet from this stand-point differ manifestly in a greater or 
 less degree. Of the truth of this statement we shall be convinced later. 
 
 In general, it may be stated that pain, properly speaking, does not 
 characterize organic disease of the heart as we commonly meet it. Of 
 course, there may be more or less prsecordial anxiety or oppression, or 
 there may be pain in the vicinity which is of stomachal or hepatic 
 origin; but acute cardiac pain is very rare. For this reason it has 
 become almost an axiom for clinicians to say when acute cardiac pain is 
 complained of, it is more than likely no organic disease of the heart is 
 present. Perhaps this affirmation is too positive or dogmatic, since I 
 am confident functional distress may occur which is dependent upon 
 obvious tissue changes. 
 
 In true angina the pain is very characteristic, and as I have said, 
 ordinarily means organic changes of the heart structure. First of all, 
 
120 ANGINA PECTORIS. 
 
 the pain of angina is marked by its great intensity. In no other dis- 
 ease, perhaps, is this so true. When the anginoid attack occurs, if the 
 patient is walking or exercising in any way, he stops immediately and 
 holds himself as quiet as possible, only taking hold almost involun- 
 tarily at times, so great is his distress, of the nearest object which will 
 give him support. Otherwise, he may merely stand rigidly, having 
 come to a short stop, with his arms lying unconsciously by his side, or 
 else one hand is pressed firmly in the precordial region, as if to 
 ameliorate in a measure the subjective agony by so doing. During the 
 attack the pectoral and other muscles of respiration scarcely move, and, 
 indeed, breathing comes almost to a stand-still for a while. In this 
 we perceive at once the great dissimilarity with an attack of cardiac 
 asthma, in which the efforts to breathe are so forcible and striking. 
 And yet there are numerous instances in which the cardiac asthmatic 
 features are most notable and where the "angina sine dolore" of 
 Gairdner is also present, 1 as Osier states, after a masterly summary of 
 the differential diagnosis of these two states, " when we recall to mind 
 the features of the attack in cardiac asthma and in certain anginal 
 seizures, the similarity of the condition, as Huchard remarks, to an 
 acute emphysema, the views of Von Basch 2 appear to possess at least a 
 reasonable probability " (p. 85). 
 
 The locality of the pain in angina is not always the same. Fre- 
 quently it is located over the precordial region. At times, however, it 
 may be situated in the upper portion of the chest, or again, but in rela- 
 tively few instances, it may stretch like a heavy bar across the xiphoid 
 cartilage and the adjacent structures. Under these circumstances the 
 pain may radiate directly through the chest and be felt even in the 
 back. The pain has been likened to a heavy weight or crushing 
 pressure, as though the thoracic parietes must almost meet. The pain 
 is also said to resemble that of some terrible griping, as though the heart 
 were held firmly in the clutch of some terrible monster. All these sen- 
 sations, and numerous others, have been described and dwelt upon by 
 writers, who doubtless have used their imagination at times to supply the 
 descriptive powers of the patient. Suffice it to add that the pain is of 
 a frightful sort and quite unlike any other we are familiar with. Often 
 the radiation of the pain is toward the left arm, and in that case is 
 usually carried through the forearm also and to the fingers. The ring 
 and little fingers are said to be usually affected. Very rarely the pain 
 extends to the right arm. When it does it radiates likewise in one or 
 other direction mentioned. 
 
 According to Broadbent, the pain of angina often originates in the 
 
 1 Osier. Angina Pectoris and Allied States, p. 82. 
 
 * These are : " Cardiac dyspnoea follows swelling and diminished elasticity in the lungs." 
 
ANGINA PECTORIS. 121 
 
 left wrist, and from there travels upward through the left arm and 
 toward the chest — or again, as Osier states, although originating in the 
 chest, 1 " was felt very severely about both wrists." This must be an 
 extremely rare expression of the pain. I have never met it, nor do I 
 find it mentioned by others. It is clear that the relations of brachial 
 symptoms 2 (neuralgia) to angina pectoris are various. Sometimes, 
 though infrequently, there are no pains in the arms, even in quite severe 
 attacks of angina. Again, the brachial symptoms are very prominent, 
 begin the attack of angina, and last longer than it does. The fact is, 
 however, that the description of pain and its radiation, especially 
 where it has the remarkable intensity of that belonging peculiarly to 
 angina, must be somewhat inaccurate at times. In any event, it could 
 only be obtained after the attack has passed, and I am inclined to 
 believe that only exceptionally the patient could give any graphic and 
 truthful description of it. What is literally true is that the patient 
 has the impression vividly marked of impending dissolution, and it is 
 this sense, together with the character, site, and evident intensity of the 
 pain, which are almost pathognomonic of angina. 
 
 I know of few things more remarkable in descriptive medicine than 
 the account given in the life of Dwight L. Moody by his son, of the 
 anginoid attack near the close of the life of the great evangelist. In 
 this case there was no terror or mental distress, as I believe, because his 
 faith and works fixed him, as it were, on a rock. But in very many 
 instances there is unquestionably great terror and mental distress. 
 This is pictured often in the countenance which has that gray, ghastly, 
 drawn look which once seen leaves an indelible impression upon the 
 observers who may be near. The different radiations of the pain in 
 angina are, no doubt, reasonably explained by the position of the car- 
 diac plexus. The site of this plexus near the heart would serve to 
 strengthen this view. In addition, we have its divisions and communi- 
 cations which appear to justify this interpretation. 
 
 According to one eminent observer, the pain originates probably in 
 the central nervous system. This writer also explains its radiation and 
 extension by affirming that it proceeds from the spinal cord. One 
 thing is pretty certain, if we may judge by the few thorough observations 
 we have recorded of these cases, and it is that there is no pressure out- 
 side of the heart on the plexus from any form of aneurism or other 
 kind of tumor. While the heart may or may not be enlarged accord- 
 ing to circumstances, this enlargement, even though present, does not 
 explain rationally the anginoid symptoms. 
 
 Cardiac hypertrophy and cardiac dilatation are very frequently met 
 
 1 "Angina Pectoris and Allied States," p. 42. 
 1 Boston Med. and Surg. Journ., March 14, ]901, pp. 256, 257. 
 9 
 
122 ANGINA PECTORIS. 
 
 with, and yet in the vast majority of these cases there are no anginoid 
 symptoms, properly speaking. Leaving aside these instances, there are 
 a few where the heart is seemingly of normal size and volume, and we 
 must, therefore, seek an explanation of anginoid pains in some other 
 direction. Even in acute cardiac dilatation, no intense pain is felt, 
 and yet we should have in just such cases pressure on or distention of 
 nervous fibres under the endocardium. Moreover, this pressure or dis- 
 tention must be very much greater in patients thus affected than in 
 those suffering with angina where no similar condition exists. During 
 the attack the patient is usually very pale, and the pallor has a certain 
 gray, ashy hue which is indicative of the serious condition which occa- 
 sions it. Together with this pallor there is extreme weakness, and a 
 faint feeling, which cannot be resisted, overwhelms the individual wha 
 is attacked. The pulse shows by its character, oftentimes upon what 
 this weakness in part depends. It is frequently small, feeble, irregular, 
 as though the poorly acting heart could not send the blood to the 
 extremities. Again, singular' to say, it is almost unchanged, at least so 
 far as we can appreciate by our tactile sensations. In the former 
 instance, it is probable that there is present a spasmodic contraction of 
 the peripheral arteries; in the latter, we must assume that no' such 
 spasm exists, or, indeed, that arterial changes are so advanced that no 
 marked impression is made upon their contractibility even by the most 
 intense pain and disturbance of the central organ of circulation. 
 
 Frequently an attack of angina terminates by the sudden explosion of 
 gas from the stomach. Hence it is often stated and familiarly accepted 
 that flatulent dyspepsia is an immediate and efficient cause of a true 
 attack of angina. In my experience this is scarcely true, and I am 
 more inclined to the belief that it is especially in cases of pseudo-angina, 
 that we should expect to find symptoms of stomachal weakness or 
 intolerance. While admitting this, we should also not completely 
 ignore the fact that the stomachal conditions which occasion flatulence 
 may at times appear to be of considerable importance, taken with other 
 exciting factors, in bringing on an attack. There may be, as Broad- 
 bent points out, a certain sympathetic relationship between the terminal 
 fibres of the vagi in the stomach and those in the heart. Many facts 
 would serve to demonstrate this possibility. Certainly, even in cases of 
 marked cardiac weakness, where there has never been a true anginoid 
 attack, dyspepsia of an acute and very distressing type will frequently 
 follow undue fatigue of any sort or any severe shock to the nervous 
 system such as distressing or alarming news may readily excite. 
 
 A phenomenon which is somewhat curious is the fact of an intense 
 desire to urinate during the period of an attack, even though the effort 
 is vain, simply because the bladder is frequently entirely empty. 
 This statement may not invariably be true. I have known many a 
 
ANGINA PECTORIS. 123 
 
 time emotional excitement to prevent absolutely for a while the con- 
 tractile power of the bladder being exerted, and where, as was proven 
 later, the bladder contained a considerable quantity of urine. It 
 requires a very slight degree of annoyance or mental disturbance in 
 men past middle life to prevent frequently their power to void their 
 urine. Of course, the contrary of this is true, especially among women 
 of a neurotic type, and who are still relatively young. The quality of 
 urine of low specific gravity passed by them at times, in a very brief 
 period, is often very great. In the differential diagnosis of true angina 
 with pseudo-angina this point should be borne in mind. During the 
 attack where it is severe, perspiration will flow almost constantly from 
 the patient. His face and neck and hands may be covered with it. It 
 is cold and clammy, and lends additional significance to the gravity of 
 the other symptoms. 
 
 The time during which an attack lasts is very variable. Sometimes 
 it is over after a few seconds, although during this short period the 
 agony is fearful. Again, the attack is prolonged for several minutes. 
 Some authors state that the attack may occasionally last throughout an 
 entire night, and that during all this time the patient is unable to move 
 at all on account of the intense pain, and, moreover, is perspiring pro- 
 fusely the entire period. I must confess that I have never seen any 
 attack of this sort, and am inclined to consider them very infrequent. 
 
 It is highly probable, moreover, that in a case of true angina depend- 
 ing upon advanced degeneration of the coronary circulation, which 
 would probably be present under such circumstances, the intense pain 
 of anginoid character would terminate life more rapidly. Here, again, 
 I should be disposed to hold the view that a neurasthenic or hysterical 
 element was present, which gave strength and exactness to the true 
 diagnosis, viz., pseudo-angina. 
 
 It must be admitted, of course, that there are instances in which the 
 attacks are certainly anginoid in character, although they do not reach 
 their complete development. This fact may be explained by stating 
 that the patient, having suffered from attacks previously, so soon as he 
 fully appreciates that one is coming on simply stops still and avoids all 
 possible exertion until the attack has completely passed away. In these 
 examples there may be pain in the chest, but without radiations toward 
 the arms or fingers. Of course, if the pain is diminished in violence, 
 there is less dread attached to the seizures, and the patient does not 
 expect to die at any moment. Broadbent and others speak of anginoid 
 attacks sine dolore. In some instances the chief danger arises from a 
 syncopal attack in which a patient may suddenly expire. It may be 
 that these attacks had been originally painful, and it was only subse- 
 quently that they lost this characteristic feature entirely. I should 
 expect, in such an instance, to find at the autopsy either marked fatty 
 
124 ANGINA PECTORIS. 
 
 degeneration of the heart walls independent of coronary changes, or else 
 advanced aortic regurgitation. Wherever the coronary circulation is 
 suddenly obstructed with an embolus or thrombus, the breast pang 
 seems to be almost an invariable accompaniment. In those cases where 
 the attack has evidently been brought on by exposure or exertion, it 
 does not usually last long, and when the accidental occasion of the 
 attack has disappeared, the seizure itself is apt to dissipate itself rapidly. 
 Wherever the attack comes on spontaneously, as it were, without any 
 accidental efficient cause being evident, it is apt to last a longer time, 
 and only to pass away little by little and slowly. Occasionally these 
 attacks are the most alarming in reality, and herald a fatal termination 
 in the not distant future. 
 
 Among the causes which act efficiently in bringing on an attack of 
 angina are primarily exertion. We are apt to say over-exertion when 
 the attack has taken place. This over-exertion may be a brisk, rapid 
 walk, or the patient may be walking leisurely and without effort when 
 the seizure occurs. Usually, however, it is when a walk has been pro- 
 longed and there is already a feeling of fatigue that the angina is felt. 
 It has been noticed that whenever exertion takes place soon after a 
 meal an attack is more apt to occur. It may be because digestion, if 
 slow and torpid, is thus interfered with, and gases which are generated 
 and accumulate in the stomach press against the diaphragm and indi- 
 rectly against the heart, and thus, by causing some displacement of this 
 organ, may occasion notable interference with the circulation. 
 
 One reason, no doubt, why attacks occur at times during sleep, is 
 
 because flatus is prone to accumulate in the stomach and intestines 
 
 during sleep, and considering this together with the fact that in the 
 
 horizontal position we have more pressure of the abdominal viscera 
 
 upward, we realize readily conditions which are powerful in causing 
 
 distress. 
 
 The liability, under these circumstances, to an attack is increased 
 
 notably by a feeble circulation. Moreover, as we know, the circula- 
 tion is always less active in repose, and this state is what prevails 
 during sleep. A loaded rectum is, also, a condition to be avoided, and 
 anyone subject to constipation must see to it that the bowels are properly 
 evacuated. The distended bowel may perhaps act in a reflex manner, 
 as well as by direct pressure. 
 
 The influence of cold is sometimes very evident. This is particularly 
 true when a patient is walking against a cold wind. Nothing more is 
 required than this sometimes to precipitate an attack. On the other 
 hand, mild, warm weather is conducive to well-being, and sufferers 
 from angina will often escape attacks during long periods when the 
 weather is free from rapid changes and remains relatively balmy. It 
 is essential at night for a patient to see that the bed is. comfortably 
 
ANGINA PECTORIS. 125 
 
 warm and that no chilling of the surface ensues; otherwise, an attack 
 will often follow. This precaution may be readily attended to with a 
 hot-water bottle or heated bricks. Gentle friction of the surface of the 
 body, perhaps, before the patient retires, is also a proper precaution to 
 take. The wearing of long woollen stockings, and particularly those 
 which are somewhat loosely knit and allow free transpiration, is espe- 
 cially desirable, so as to keep the extremities suitably warm. I know 
 of no small detail so important as this in all affections in which the cir- 
 culation is notably impaired, and, of course, it becomes doubly impera- 
 tive in warding off painful attacks which are too frequently occasioned 
 by local chilling of the feet. 
 
 In view of the fact that dyspepsia is such a frequent symptom of 
 angina, and appears as an efficient cause, in the judgment of a few 
 writers, quite as often as an effect, it is important to avoid all late or 
 too abundant dinners. The food at this meal should be of the simplest 
 kind, and no overloading of the stomach should be permitted. In a 
 similar way, no sauces, condiments, or insufficiently cooked food should 
 be tolerated. 
 
 Whenever an attack has occurred, it behooves the patient to be more 
 than usually circumspect in all his doings, not to bring on another one. 
 This is especially true of any exertion which seemingly has been the 
 direct cause of an outbreak. And yet this counsel is sometimes almost 
 unnecessary, because the patient's own feebleness, which follows a pri- 
 mary attack, will compel him almost to walk very slowly and deliber- 
 ately, even if he walks at all, for some hours or days subsequently. 
 No doubt these anginoid attacks would not occur if the heart had suffi- 
 cient reserve force to respond adequately to the call made upon it. 
 Unfortunately, it has not, and it is therefore evident, in many instances, 
 that the attack is directly occasioned when we reach final causes, by the 
 manifest inability of the heart to respond to the call made upon it for 
 increased vigor. 
 
 Angina pectoris is not necessarily connected with any special lesion. 
 Practically, it is almost unknown to have either stenosis or incompe- 
 tence of the mitral valve appear as a direct, efficient cause of it. It is 
 true, however, when there have been several attacks of angina, it is 
 not infrequent to observe mitral incompetence arise subsequently. In 
 some of these instances it has been noted, where aortic incompetence 
 already existed, that this affection was ameliorated as regards its symp- 
 toms, and that the anginoid attacks also became less severe. The 
 explanation appears to be in the lessened blood pressure thus brought 
 about, as shown in the arterial pulse and in the diminished accentuation 
 of the aortic second sound. Musser 1 has insisted upon the importance 
 
 ' Transactions of tbe Association of American Physicians, vol. x. p. 85. 
 
126 ANGINA PECTORIS. 
 
 of this finding, and has reported several examples in his own experience. 
 Broadbent 1 has also specially emphasized similar instances. 
 
 Angina is frequently connected with fibrous myocarditis, and at the 
 autopsy such organic change in the heart muscle is apt to be found. 
 So usual is this condition that Gibson states it is almost a surprise not 
 to find it. When fibrous myocarditis is noted, it is frequently accom- 
 panied with evidences of arterial degeneration. The coronary arteries 
 are usually implicated. Especially is this true where aortitis is present. 
 The lesion may be limited to their origin, which is sometimes narrowed 
 and thickened. The arteries may also be affected in a considerable 
 extent, and the organic changes may be considerably advanced. Occa- 
 sionally they have merely lost elasticity ; in more pronounced alteration 
 they may have become markedly atheromatous, or, indeed, calcified. 
 
 According to Douglas Powell, fatty degeneration of the heart walls 
 often exists. Sometimes, indeed, the heart is so much degenerated that 
 it is easily torn, and the finger sinks into it on slight pressure. Some- 
 times, to the naked eye, the fat exists only in patches, affecting merely 
 the papillary muscles or different areas of the ventricles. Even in these 
 instances, however, if we make use of the microscope, we are apt to find 
 considerable degeneration of the walls, where there has been no real 
 change of coloration. In a few instances the microscope shows almost 
 complete disappearance of the muscular fibres. 
 
 As a concurrent condition with fatty degeneration, we discover more 
 or less advanced changes of the coronary arteries, very similar to those 
 already mentioned in connection with fibrous myocarditis. These evi- 
 dences of fatty degeneration are particularly found, of course, where 
 the fatal termination appears to be intimately dependent upon the pre- 
 vious anginoid attack. It should be remarked in this place that we 
 often have both anterior conditions, viz., that of fibrous myocarditis or 
 of fatty degeneration, without having attacks of true angina. Accord- 
 ing to Gibson, the relations of angina with endocardial lesions is 
 not so distinct. It is true, of course, that degeneration of cardiac 
 walls may often cause it, and, therefore, it is frequently found at the 
 autopsy. The earlier writers, like Morgagui, certainly attached angina 
 directly to the existence of aortic disease, and in one of Heberden's 
 cases, where the autopsy was made by John Hunter, this affection is 
 duly recorded. On the other hand, we know that the most advanced 
 changes with ossification may exist at the aortic orifice, and yet there 
 may be present during life no morbid symptoms at all. 2 These instances 
 must be somewhat exceptional. What is true is, where aortic lesions have 
 been proven at autopsy, often pain has been noted prior to death. No 
 
 1 British Medical Journal, 1891, vol. i. p. 747. Quoted by Osier. 
 
 2 Sernple, p. 104 et seq. 
 
ANGINA PECTORIS. 127 
 
 doubt, this pain has been in part due, at least, to interference with the 
 coronary circulation, caused by accompanying aortitis, with which there 
 may also be a certain degree of dilatation, or, indeed, a sacculated 
 aneurism. Arterial degeneration, especially arterio-sclerosis, is often 
 adjoined to attacks of angina. Where the coronary arteries are degen- 
 erated, and where the angina is seemingly dependent upon this condi- 
 tion, we should not lose sight of the fact that the other arteries, being 
 degenerated, are also doubtless contributory. The affection of the 
 coronary arteries through sclerosis and consequent narrowness, prevents 
 a sufficient blood supply reaching the heart, and hence interferes with 
 its nutrition. A thrombus or embolus may obstruct the vessels, but it 
 is doubtful whether one or the other of these conditions causes angina. 
 (Gibson.) One thing is sure, viz., we often find calcification of these 
 arteries without previous anginal attacks. Adherent pericardium may 
 be found, but does not occasion anginal attacks unless accompanied by 
 a lesion at the aortic orifice, 
 
 Angina has been observed following injuries to the chest walls. In 
 these cases the aorta may have been affected. Broad bent states its 
 presence occasionally in malarial fever. It may also be present in 
 advanced diabetes where the arteries may become thickened, thus giv- 
 ing rise to increased tension, and followed by attacks of true angina. 
 It is not infrequent to find anginoid attacks occasioned evidently by 
 the presence of the gouty poison. In these cases the prognosis is 
 only serious where the intracardiac changes are already advanced, as 
 shown by the weakness and irregularity of the heart's pulsations. In 
 some of these cases we find notably fibroid myocardial changes in 
 patches or disseminated. Even in these instances, prior to death, there 
 may have been a few or no threatening cardiac symptoms. In a few 
 rare cases neuritis of the cardiac plexus and also of the phrenic nerve 
 has been noted (Lancereaux, Peter) where anginoid attacks have 
 occurred. The view of Semple is, indeed, that angina considered as an 
 idiopathic disease is connected with an affection of the pneumogastric 
 or phrenic nerve. Of course, it is difficult always to pronounce what 
 the precise structural changes are. Still, they are doubtless present, 
 and later will be discovered. Meanwhile we are forced to rank a few 
 such instances among the " neuroses." Frequently, doubtless angina 
 is associated with minute structural changes which only subsequent 
 close investigation will determine Flint is evidently of the opinion 
 that the connection between angina and organic lesions of the heart is 
 rare. Thus he has only observed fifteen cases in 388 cases of the latter. 
 Again, Flint says that in ten years he has noted only four cases of true 
 angina, that is to say, where the disease was unconnected with cardiac or 
 aortic lesions. It is clear that in all instances where there is present an 
 organic lesion of the heart or arteries, whatever suffering, if any, the 
 
128 ANGINA PECTORIS. 
 
 patient may experience should be directly explained by them. This 
 leads to the conviction that only those cases in which no such lesion is 
 discoverable should be ranked among the true cases of angina. As a 
 rule, when sudden deaths occur in what has been called angina, 
 pathological lesions sufficiently explanatory are found at the autopsy. 
 
 The condition of the heart during an attack of angina has been 
 believed to be one of spasm. At least, this is the opinion of some 
 writers. It is certainly true of Heberden, who first so accurately de- 
 scribed these attacks in his commentaries. This does not seem to be 
 altogether a tenable opinion, if one has regard to the fact that the heart 
 has rarely been found thus contracted. 
 
 Usually the heart stops in diastole, and is found after death in a 
 relaxed condition. Again, during life, while the pulse at the wrist is 
 sometimes irregular and weak, it never disappears entirely, which it 
 certainly would if the heart were in a state of forcible, spasmodic con- 
 traction. 
 
 It has been supposed that the heart during an attack presented a 
 sort of hour-glass contraction not dissimilar to that of the uterus. This 
 may be, and yet it would be difficult to prove. Broadbent confesses in 
 this connection that he has a very imperfect notion of what the condi- 
 tion of the heart really is during an attack. The evident fact is that 
 during a paroxysm of angina stress is put upon the heart to which it is 
 quite unequal to respond, and thus it shows its considerable lack of 
 power. Often the stress put upon the heart is due to the continuous 
 high tension of the peripheral arteries. Occasionally, however, there 
 is low tension in the peripheral circulation, and in these instances, if 
 there occur a sudden general arterial spasm, the amount of work thrown 
 upon the heart becomes rapidly much greater, and consequently the 
 heart shows relatively greater distress than where the peripheral resist- 
 ance is continuously high and exaggerated. In those cases where there 
 is marked and continuous high tension in the peripheral arteries we 
 might suppose that pain in angina was explained by greater pressure 
 thrown upon the heart. This can scarcely be true when we consider 
 how many such cases escape any such pain. Again, in acute dilatation 
 of the ventricles, we have great pressure brought upon the heart walls, 
 and yet no pain results. Neuralgic predisposition is occasionally given 
 as an explanatory cause. This is scarcely true if we mean by that an 
 acquired or evident neurotic tendency, since this disease occurs more fre- 
 quently with men than with women. It would seem as though from the 
 fact that when the attack occurs immediately, the patient stops doing 
 anything he is occupied with, or exercising, if that be what he is about, 
 that there is a certain pre- ordered protective arrangement internally 
 to guard against these outward manifestations of man's life. (Broad- 
 bent.) 
 
ANGINA PECTORIS. 129 
 
 Pain, according to Bramwell, 1 is due to irritation of the nerve ter- 
 minations in the walls of the heart itself. He admits, however, that 
 the theory of irritation due to spasmodic contraction is plausible, and 
 compares this opinion with what occurs in the calf muscles, spasmodi- 
 cally contracted, in ordinary cramp. 
 
 Attacks of false angina often resemble those of the real kind. Some- 
 times the description of the attack by friends will enable us to reach a 
 correct diagnosis. If the patient becomes pale, anxious, and shows 
 signs of great distress, it may not of necessity be true angina. If, on 
 the contrary, there be no such changes evident, we can be very sure 
 that it is only an attack of pseudo-angina. There is much unreliability 
 in the patient's accounts, mainly because they are apt to read up about 
 these attacks, and often give an exaggerated idea of their own sensa- 
 tions. Age will throw some light upon the diagnosis. Under forty 
 years of age in the male, angina occurs very rarely, unless there be a 
 pronounced lesion at the aortic orifice or aortitis. In females it is rare 
 at any age, although attacks of pseudo-angina are not infrequent with 
 them, especially those of an undoubted neurotic temperament. Heber- 
 den, for example, in speaking of the cases observed by him, being in 
 number over 100, states that three occurred in women, one in a boy 
 twelve years of age, and the others in men near or over fifty years. 
 
 Usually the first attacks of angina occur during physical exertion. 
 Later on they may come on severely and more readily, and then we 
 may make the diagnosis surely, even though the determining cause is 
 slight. The physical examination will reveal, in case of true-angina, the 
 changes mentioned in the aorta or at aortic orifice. Where the attack 
 at first comes on without exertion and at a fixed period after ingestion 
 of food, it would seem to be of digestive provenance or pseudo-angina, 
 and ordinarily due to a dyspeptic attack. Unless history, nature, and 
 onset of attack all concur together with physical signs to establish diag- 
 nosis of true angina, we should lean strongly to diagnosis of pseudo- 
 angina, and almost invariably, if we can discover any facts to support 
 this diagnosis. If we leave out attacks of pseudo-angina which are 
 evidently neurotic or of hysterical nature, we can usually find in some 
 digestive disorder, particularly of the stomach, a sufficient explanation 
 of them. There are eructation, marked flatulence, pain, occasional 
 attacks of nausea, or vomiting, which all point in this direction. A 
 combination sometimes found is that of dilatation of the stomach, with 
 high arterial tension. If the heart be affected in these cases and they 
 are improperly treated, a fatal result may not infrequently follow. If, 
 for example, digitalis or nitroglycerin be alone used, or the Schott 
 treatment advised and carried out without any care of the stomach, and 
 
 1 Diseases of the Heart, p. 676. 
 
130 ANGINA PECTORIS. 
 
 especially if the subject be old, such a denouement may not be a 
 surprise. 
 
 The prognosis of true angina is often uncertain ; and yet we have 
 certain conditions which guide us to make it correct. We should 
 estimate carefully the relative predominance of the two factors often 
 producing it — on the one hand, degenerated heart walls, on the other, 
 vascular changes. If there be high arterial tension present, and if at 
 the same time the heart action is forcible and the aortic second sound 
 marked, we may hope by proper treatment to modify these conditions 
 for a while with the use especially of nitroglycerin and the nitrites. 
 Again, if over-exertion and excitement bring on the attacks, or if flatu- 
 lent dyspepsia be a decided and powerful influence in producing them, 
 we should hope to avoid with care and treatment their natural outcome. 
 
 On no account should the patient walk hurriedly, especially in going 
 up hill. He should also never take even a moderate walk until a 
 certain time had elapsed after his last repast. 
 
 Attacks of angina which accompany aortic disease may last a con- 
 siderable time without bringing on a fatal result if carefully watched 
 and guarded. The worst cases are those which recur in the night or at 
 times where no accidental cause is present and avoidable which occa- 
 sions them. Again, if examination is relatively negative, if the heart is 
 of normal size, without manifest lesion of any kind, and yet its action 
 is feeble, its impulse scarcely felt, and the pulse usually, if not invari- 
 ably, of low tension, these give great anxiety by reason of the vagueness 
 and uncertainty as to the conditions which may be present and at any 
 time become imminently threatening. 
 
 The apparent severity of two attacks may be similar, and yet the 
 relative danger of them may be absolutely different. It is difficult, 
 therefore, at times to make anything like a sure forecast. Of course, 
 where there are pronounced cardiac and arterial changes, and where, 
 in addition, heart failure has followed hypertrophy, the outlook is 
 assuredly very grave indeed. If, at the same time, aortic regurgitation 
 also be present the prognosis becomes even more serious. In a similar 
 way, if chronic renal changes exist the future of the patient must 
 appear dark and imminent. Gibson states that the prognosis of those 
 affected with fatty degeneration is far less serious than the preceding. 
 Provided always the external and avoidable causes of aggravation are 
 prevented, such patients may often live many years. Of course, toxic 
 angina is far less grave. As a rule, with the removal of the cause the 
 case becomes curable. In neurotic cases, while we should expect fre- 
 quent recurrences of the paroxysms, it is wholly improbable to have a 
 fatal termination. 
 
 In this catagory may be placed frequently the so-called idiopathic 
 cases. They are often extremely painful, but as no incurable lesions 
 
ANGINA PECTORIS. 131 
 
 exist, they tend to improvement or recovery if properly managed. Of 
 course, we should be careful in making even in these cases too favorable 
 a prognosis, since there may be some underlying structural change of 
 the heart walls or coronary arteries which, during life, could not be 
 determined. There are unquestionably, according to Semple, cer- 
 tain cases of pure angina in which the autopsy reveals no organic 
 changes. 
 
 The treatment of angina depends upon what is the apparent or 
 obvious cause. In many instances, owing to the difficulty of tracing 
 accurately to what the attack is primarily due, our treatment must be 
 essentially empirical. First of all, we must consider the general health, 
 and from this point of view our treatment should be hygienic. The 
 means at our command are here what pertain to air and light, rest and 
 exercise, food and drink. After these have all been inquired into and 
 regulated, as far as may be, we' naturally seek for the proper medicinal 
 remedies to meet the indications of each special case. In general, also, 
 the efficiency of our treatment will depend much to what degree we may 
 be able to relieve peripheral resistance to a heart frequently weakened. 
 If, perchance, we find between the regular pulse beats evidence of 
 increased tension to our tactile sensations, we may often reduce this by 
 appropriate remedies. Still, in order to recognize it, we must at times 
 examine the heart and arteries at different periods, before and after 
 exertion. Not infrequently the arteries are notably degenerated, hard, 
 thickened, tortuous, and even calcareous. We can then do little to 
 affect them directly. Yet, the capillary system, in which there may be 
 notable resistance without excessive changes, and which has caused in 
 a measure the arterial and cardiac changes, may be still favorably 
 influenced by appropriate drugs, and account should be kept of this 
 fact. In gouty conditions the peripheral circulation may show increased 
 tension, although not visibly degenerated, and this condition, of course, 
 may be favorably influenced by appropriate medication. 
 
 In these latter cases the ordinary treatment with a mercurial, fol- 
 lowed by a saline, once or twice a week, will lower arterial pressure. 
 Between times the use for a while continuously of iodide of potash and 
 colchicum may be of signal benefit. The employment of bitter tonics, 
 if the indication presents, and the proper regulation of the diet is, 
 of course, useful. According to Powell, hop, columba, and chiretta are 
 better tonics in these cases than quinine and strychnine. In the " neu- 
 ralgic bouts," to which they are prone, he praises quinine and phen- 
 acetin. Where angina occurs with marked aortic disease it is difficult 
 sometimes to know to what extent we may be able to help the attacks 
 by reducing tension of the pulse. Where the pulse remains feeble 
 between the attacks, and the heart has a weak impulse, we should care- 
 fully endeavor to help with cardiac tonics, but frequently we can be of 
 
132 ANGINA PECTORIS. 
 
 little real service in view of the pronounced degenerative changes 
 present in the heart and arteries. Occasionally arsenic, combined with 
 iodide of potassium and nux vomica, is useful where the arterial tension 
 is not too pronounced. Preference may be given in many instances to* 
 the sodium salt of the iodide, both between and during the attacks. 
 According to Schott, it is less prone to cause heart failure ; but even 
 this salt is "apt to destroy the molecules of albumin" if continued too 
 long or in increasing doses. Milk is the best menstruum for either 
 salt, as in this way stomachal intolerance is less likely to occur. In 
 these and other cases we should try to preserve the use of the nitrites 
 and nitroglycerin for the attacks. Formerly the diffusible stimulants, 
 like brandy, ammonia, lavender, camphor, etc., were much used for 
 these attacks. Now they are almost abandoned for nitroglycerin and 
 nitrite of amyl. These latter are particularly useful in relieving pain, 
 and to accomplish it they dilate peripheral arteries. Nitrite of amyl 
 by the rapidity of its action is preferably employed. Nitroglycerin 
 and the sweet spirits of nitre produce similar effects in different degrees. 
 All of these are free from dangerous effects, as a rule; not so of nitrite 
 of sodium, which may produce alarming results. (Gibson.) Nitrite of 
 amyl and nitroglycerin dilate arteries, increase frequency of pulse and 
 respiration, and reduce irritability of the nervous system. Where 
 increased acceleration of the pulse and respiration are already present 
 the nitrites must be employed with great care, as they might possibly 
 cause greater distress. While they are said to be heart stimulants, they 
 mainly cause relaxation of the arteries and also of the cardiac muscular 
 fibres. (Broadbent. 1 ) 
 
 The nitrites have their drawbacks also in the fact that patients find 
 so much relief from their use that they use them too frequently and 
 injudiciously. A word of warning should be thrown out because life 
 is sometimes shortened by their inconsiderate use. Glycosuria has been 
 produced by them, it is stated. In many instances the nitrites are less 
 useful than iodide of potash. Nitrite of amyl may be carried about 
 with one so as to be used immediately. The nitrite of amyl in glass 
 globules, of 3 to 5 minims, may be in a silk bag and broken upon a 
 handkerchief and inhaled as required. The nitroglycerin tablets, one 
 one-hundredth of a grain, may also be taken in doses of one or two when 
 attack occurs. They do not act as rapidly as the nitrite of amyl, but 
 their effect is more prolonged, and on that account may be more valu- 
 able in certain cases. 
 
 Some cases, however, are not relieved by nitroglycerin tablets and are 
 relieved by nitrite of amyl. According to Broadbent, such cases have 
 seemed to him to originate in the right ventricle. 
 
 1 This opinion about heart fibres I do not share save very exceptionally. 
 
ANGINA PECTORIS. 133 
 
 It is the belief of Dr. B. Addy 1 that we have in erythrol tetranitrate 
 a remedy superior even to "nitroglycerin," its effects being very rapid 
 and more lasting. Tablets of one-half grain each were given by him 
 twice or three times a day. They did not cause headache, and the 
 remedy soon checked the attacks. It is true the patient died after a 
 fortnight of syncope, but during this period great relief from suffering 
 was experienced. 
 
 Sometimes, where the heart is weak and the nitrites do not relieve, 
 although they may relax the peripheral circulation, we must recur to 
 the old stimulants. In addition, a turpentine stupe, or mustard leaf, or 
 poultice may be applied over the chest and will occasionally afford a 
 measure of comfort. Whenever these local applications fail, great 
 relief is obtained from a hot-water bag at a temperature of 140° F. 
 to 170° F., "moved with light touches over the whole chest." 2 If, 
 despite all this, the attack is prolonged and unrelieved, we must give 
 a hypodermic injection of morphine and atropine, using at first small 
 doses, and later, if need be, becoming bolder, and using larger doses. 
 It is well to make injections deep in the muscle, where the circula- 
 tion is more active than in the cellular tissue under the skin. In 
 some instances we should recur to chloroform inhalations as being 
 the only hope of relief to the patient. At times they are undoubt- 
 edly dangerous, and " especially is this believed to be true if fatty 
 heart is present. As a matter of fact, however, fatty heart cannot 
 always be diagnosed with accuracy. The apex may be strong and the 
 pulse regular and good, and yet fatty heart may exist, and sudden 
 death follow. Again, moreover, it has been shown that chloroform 
 may be given safely where fatty heart later is known to exist by the 
 revelations of the autopsy. We must relieve intense pain, however, 
 even if there be risk, and it can only be done at times by such agents. 
 (Balfour.) 
 
 In cases where there is marked heart failure, ether or brandy should 
 be employed hypodermically in doses of gss to 3j. To each hypo- 
 dermic injection one or two tablets of one one-hundredth of a grain of 
 nitroglycerin may be added. The latter should be employed with 
 caution, however, as occasionally considerable soreness and even ulcera- 
 tion of the skin may result. 
 
 Theodore Schott does not value very highly digitalis or strophanthus 
 in cases where the heart requires stimulation, even in uncomplicated 
 forms of angina pectoris caused by sclerosis of the coronary vessels. 
 
 Oxygen inhalations are often also useful, not only to satisfy the air 
 hunger, due to obstruction of circulation in the lungs, but also to 
 stimulate cardiac circulation and help nutrition of its muscles, and thus 
 
 1 British Medical Journal, May 6, 1899, p. 1089. a Lancet, September 8, 1900, p. 726. 
 
134 ANGINA PECTORIS. 
 
 get rid of effete material which interferes with proper metabolism. 
 (Powell.) In these cases the oxygen must be used with a funnel near 
 the nose and mouth, so that it may be inhaled frequently and without 
 effort. As corroborative of the extreme value of inhalations of oxygen 
 in the treatment of some severe cases of angina pectoris, I would refer 
 to one recently reported in the British Medical Journal for December 1. 
 1900, p. 1568. 
 
 Rest in bed for a time is often desirable after acute paroxysms have 
 passed, but later it is useful, as far as possible, to get the patient back to 
 his ordinary life, with judicious restrictions. The same rules apply 
 here, however, as in other heart affections. We must remember, also, 
 that exertion which one day may seem all right, another day may cause 
 distress and oppression. This is one of the objections to Oertel's system 
 of treatment. (Broadbent.) 
 
 Physical therapy is undoubtedly useful in some instances, but it 
 must be utilized with great care. This counsel pertains particularly at 
 the present time to the treatment as instituted at Bad Nauheim, where 
 the resistant movements in conjunction with carbonic baths are prac- 
 tised. In advanced arterio-sclerosis every increase of the blood press- 
 ure which is the result of this treatment might lead to fatal conse- 
 quences (embolism, apoplexy, rupture of aneurism of heart, or aorta). 
 "Advanced sclerosis is, therefore, a contraindication for this treat- 
 ment." (Schott.) The value of many medicaments in angina comes 
 from producing low blood pressure. The balneological and gymnastic 
 treatment exercises a tonic influence, and " by strengthening heart 
 muscle, as well as by acting on cardiac nerves, distressing symptoms 
 of angina are either removed or reduced." (Schott.) 
 
 Guidance should be had in regard to the bad effects of winds, great 
 heat or cold, or rapid changes. Also, an atmosphere heavily laden 
 with moisture is injurious. Internal conditions of dyspepsia and con- 
 stipation must be warded against. A great deal of tact and good 
 judgment are required, and the patient's disposition should be thoroughly 
 known. Rest, particularly after meals, should be insisted upon, as 
 patients are particularly liable to attacks at these times. 
 
 In general, supervision and counsel must be employed about exercise. 
 Where an attack has lately occurred, it is wisdom to refrain from 
 exertion for a while, especially if the heart is weak and fluttering, and 
 afford it time to re-establish itself. 
 
TUBERCULOUS PERICARDITIS : 
 
 Followed by Remarks upon Paracentesis and Incision. 
 
 Two cases of this somewhat rare disease have been under my care 
 within the past eighteen months. In both cases autopsies were ob- 
 tained — the one complete, the other only embracing the examination 
 of the heart and pericardium. In one of these instances the pericar- 
 dium was aspirated several times; in the other it was not considered 
 necessary or judicious to operate. The history of my first case was 
 read at a meeting of the Practitioners' Society, 1 October 11, 1901, and 
 the specimen shown. The case was discussed by the members. 
 
 During the past eighteen months I have also taken care of two other 
 cases of pericarditis. Of these, one occurred as a complication of 
 Bright's disease ; the other apparently of rheumatic origin. I shall 
 refer to these later in my remarks upon paracentesis. 
 
 In certain instances of tuberculous pericarditis it has been noted that 
 there was no evidence of tuberculous deposit in the adhesions which 
 were present. In those instances more numerous, where tubercles are 
 discovered in the adhesions, they may appear like grayish areas at the 
 line of union of the parietal with the visceral layer. In 1048 autopsies 
 Wells 2 found tuberculous pericarditis 10 times, which formed about 8 
 per cent, of all cases of pericarditis recorded by him. It is not limited 
 to adults, but may occur quite frequently in childhood or infancy. It is 
 more frequent among men than women. Baginsky reports 15 cases in 
 4500 autopsies, and of these 4 were purulent. In Osier's autopsies, 1000 
 in all, there were 7 instances of tuberculous pericarditis. 3 
 
 Welch, in his report from Johns Hopkins Hospital, states he has seen 
 6 cases. Although often spoken of as frequent, it is not shown by ref- 
 erences in Index Catalogue, Transactions of the Pathological Society of 
 London, etc. Up to 1893 Osier had seen only 17 cases, and yet he 
 writes tuberculous pericarditis follows hard upon the rheumatic form. 
 In Wells' cases, where the condition was miliary and chronic, there were 
 adhesions and no fluid. In acute miliary eruption, and in those where 
 there was caseous deposit, 4 there was also more or less effusion in the 
 pericardial sac. 
 
 1 Medical Record, November 23, 1901, p. 831. 
 
 » Journal of the American Medical Association, May 25, 1901. 
 
 8 The American Journal of the Medical Sciences, 1893, p. 20. * My second case. 
 
136 TUBERCULOUS PERICARDITIS. 
 
 In one instance, where no tubercles were shown in a case of acute 
 pericarditis, the inflammation was apparently due to toxins of tuber- 
 cular origin. This opinion was supported by the fact that tubercles 
 were found extensively in other viscera. The tuberculous cases, espe- 
 cially those which are acute, result fatally. This seems to be true, also, 
 of acute pericarditis following pneumonia or Bright's disease, but is not 
 true of this complication of acute articular rheumatism. 
 
 The forms of tuberculosis as they are found in the pericardium are 
 either of miliary form or cheesy masses. When effusion exists it is 
 serous, bloody, or purulent. It may be moderate or considerable in 
 amount. Whenever the condition has existed for some weeks, it is 
 probable that the pericardial sac becomes softened and dilated, and 
 offers a very insufficient support to the heart. The clinical evidence 
 of this softening and dilatation of the pericardial sac in disease is shown 
 by its greater capacity to contain fluid. Experimentally, this capacity 
 is limited to about 700 c.c. of liquid when forced into the sac. 1 In 
 disease we know much greater quantities of fluid may be contained. 
 Even when these larger amounts are present, we can only recover them 
 in part by paracentesis, owing, as will be shown later, to the position of 
 the heart in the fluid. Soon the heart would show signs of dilatation, 
 and this condition more surely and rapidly occurs if the heart walls are 
 subjected to any increased strain. 
 
 In some instances of tuberculous pericarditis, as we know, adhesions 
 with the chest wall have developed. These adhesions, if more than 
 usually taxed, are apt, sooner or later, to be stretched, and in some 
 instances to give way. Under these circumstances the heart shows 
 signs of insufficiency very soon. 
 
 As Sequira 2 points out, the dilatation of the pericardium is very 
 important from the standpoint of ultimate prognosis, and this we can 
 readily appreciate when we consider the immediate effects of hyper- 
 trophous dilatation where passive congestion of the viscera is more 
 than likely to occur. Sequira's observations are based upon the history 
 of 130 cases of acute pericarditis and observations of 1000 cases. 
 
 In occasional instances the pericarditis seems to be due to mere exten- 
 sion from adjacent parts in which tuberculous lesions clearly exist. 
 Under these conditions the pericarditis, curious to say, may occasionally 
 be simply inflammatory. This point is affirmed by Osier. Such in- 
 stances have also been noted where the extension came from a case of 
 non-tubercular pleuritis. Likewise they have been recognized as final 
 complications of chronic tubercular states, and as a result of terminal 
 bacteremia (Wells). 
 
 In certain instances where the process in the pericardium is an acute 
 
 i Chatin. Kevue de Med., June 10, 1900. 2 British Medical Journal, June 17, 1900. 
 
TUBERCULOUS PERICARDITIS. 137 
 
 one, tuberculosis has not had time to develop there, but later we should 
 doubtless have discovered it if death from other organs affected with 
 tuberculosis had not occurred. Tuberculous pericarditis heals through 
 the formation of fibrous adhesions. In some forms, especially the caseous, 
 the healing may be accompanied with calcification. The thickening of 
 the sac wall may become very considerable. This is true of the parietal 
 wall particularly. These cases are often accompanied with a deposit of 
 numerous miliary tubercles. At the same time there is present more or 
 less effusion, which may present different characters. Often it is dis- 
 tinctly bloody. Still this is not sufficient to determine the diagnosis, as 
 it may take place in other conditions. Of the 11 cases found in liter- 
 ature by Sears, 1 6 occurred in scurvy, 3 in rheumatism, 1 in goitre, 
 1 idiopathic, in an alcoholic subject. 2 
 
 Bacilli may be found in this fluid, although sometimes it requires 
 several careful examinations to reveal them. 3 Osier reports 1 case, 
 quoted from Kast, in which tubercles have been found in the pericardial 
 effusion. F. C. Shattuck's 4 second case is another. Where this exami- 
 nation has remained negative the bacilli are revealed solely by means of 
 animal inoculations. 5 
 
 The proportion of successful inoculations is considerable. It is of 
 great value in fixing the positive diagnosis to be made. The drawback 
 to it is the time it takes to develop tubercles. 6 It is in the exudate, as 
 well as in layers of pericardium, that we find tubercle. When it 
 occurs in pericardial layers it oftener affects the parietal one and dis- 
 seminates to the left pleura. Serous effusion, when present, is fre- 
 quently surrounded by fibrous exudation, which in places becomes 
 adherent. 
 
 The myocardium may be affected with tubercular infiltration at the 
 same time as the pericardium. The miliary form is relatively unim- 
 portant as compared with the caseous. The latter penetrates deeper and 
 sometimes perforates the cardiac walls, and may surround itself with a 
 fibrinous clot. 
 
 Formerly primary cases of tuberculous pericarditis were reported. 
 To-day, thanks to a more advanced knowledge of pathology, this 
 erroneous affirmation is rarely met with. One reason is because 
 lesions formerly considered of doubtful nature are now recognized to 
 be tuberculous. Hence, when such lesions are found elsewhere and by 
 their structure are known to be of old date, we can readily appreciate 
 
 1 Boston Medical and Surgical Journal, 1898, p. 293. 
 
 2 Churtan. The American Journal of the Medical Sciences, 1892, p. 84 ; also, Michailoff, loc, 
 <cit., 1878, p. 278. 
 
 8 Report of my first case. 
 
 * Transactions of the Association of American Physicians, vol. xii. p. 194. 
 
 ' This was true in my second case. 
 
 ■• About six weeks in guinea-pig. 
 
 10 
 
138 TUBERCULOUS PERICARDITIS. 
 
 that it is from them that the infection of the pericardium proceeds. In 
 very many cases, without doubt, the infection is carried by the blood- 
 vessels ; in others the lymph channels are the evident way of transport. 
 
 Simple carrying, as it were, by extension of a tuberculous process 
 through contact, although still admitted, is not so frequently allowed 
 as heretofore. The ordinary development of tuberculous pericarditis is 
 to run a subacute or chronic course. This course may be such an 
 insidious one that for a long while the disease is latent, and no obvious 
 symptoms indicate its presence. Indeed, Osier reports only a single case 
 in which, during life, " the diagnosis of tuberculous pericarditis was 
 made with a reasonable degree of probability." If, however, there is 
 no rheumatic history, and tubercles are discovered elsewhere with pre- 
 vious symptoms of pericarditis, we should think of the tuberculous form. 
 The protracted course of the disease and the more marked irregularities 
 of temperature may indicate its presence. Sometimes the symptoms 
 occur, but are concealed by grave symptoms of other organs which are 
 affected from general miliary tuberculosis as well as the pericardium. 
 It is a fact also worthy of remark that, as a result of experimental re- 
 searches about tuberculosis, while lungs, pleura?, and mediastinal glands 
 are usually attacked, it is a very infrequent circumstance to find the 
 pericardium involved ; indeed, it is doubtful if there be any well-authen- 
 ticated cases of it. The involvement of the pericardium through the 
 lymph channels and with transport of tubercle bacilli largely comes 
 from the lungs, pleura?, and peritoneum. This infection of cardiac 
 lymphatics is doubtless carried on indirectly, so far as the former 
 organs are concerned. Owing to the free anastomosis of the lymph 
 vessels across the diaphragm, it is readily understood how a tuber- 
 culous peritonitis may cause directly the development of tuberculous 
 pericarditis. Where the tuberculous pericarditis is of caseous form 
 brought from mediastinal glands, it is probable that later on this 
 matter is carried to and produces secondary infection of the lungs and 
 pleura?. 
 
 In regard to the question of the frequency with which one layer of 
 the pericardium is affected as compared with the other, this, it appears 
 to me, is difficult of solution, despite the statement of Wells, and, in any 
 event, of no practical moment. 
 
 What is affirmed with authority is that a large proportion of cases 
 show tuberculous deposit in mediastinal lymph glands and pericardium 
 at about the same time, and frequently this is true where no tuberculous 
 deposit exists elsewhere. We are more likely to notice this dual condi- 
 tion where already the process has become somewhat a chronic one. 
 Effusion into the pericardium is more likely to occur, it is stated, where 
 caseous masses exist on its surface than where we find the small gray 
 tubercles. 
 
TUBERCULOUS PERICARDITIS. 139 
 
 Where the myocardium is affected the disease comes primarily, as a 
 rule, from the pericardium. The muscle of the heart is, however, rarely 
 thus diseased. This is especially true of the ventricle ; the auricle is 
 oftener invaded. 
 
 Tuberculous pericarditis may recover, it is stated. This is rare. 
 In general, we may say it is not directly fatal, and death subse- 
 quently occurs from tuberculous deposit in some other important organ. 
 At this time that of the pericardium may have become quiescent. 
 This, of course, occurs only in the relatively chronic forms. If it does, 
 we may find fibrous nodules in the exudate or pericardial walls as the 
 only direct evidence of a tuberculous lesion. It may be inferred, how- 
 ever, by considering the evident tuberculous condition of the mediastinal 
 glands, and through the fact that this is the sole efficient cause of tuber- 
 culous pericarditis which can be brought to light. 
 
 The most important effects, clinically, are those which are seen upon 
 the heart. In some instances there is no valvular lesion or structural 
 defect of the heart muscle, and yet there is dyspnea, cyanosis, and weak- 
 ness of pulse — all pointing to cardiac distress. The effusion, by its 
 mere pressure, seems to be the explanation of these symptoms, and its 
 prompt removal is therefore the essential and urgent indication, so as to 
 re-establish, as far as may be necessary, functional power. If this con- 
 dition is allowed to remain, even though life may not be imminently 
 imperilled, the heart soon shows the results of the external pressure 
 against which it contends by becoming enlarged with hypertrophous 
 dilatation, and by growing weaker progressively and constantly. Where 
 adhesions exist with the thoracic walls, which is often true in these cases 
 whenever they tend to chronicity, the duration of life is notably short- 
 ened. It is equally true, only more so, where the two layers of the 
 pericardium have also become adherent and the effusion has become 
 resorbed or been removed by paracentesis. In these instances life may 
 be measured by a few months. This is eminently true in pericarditis 
 affecting children. Lee Dickinson 1 reports " one solitary case in which 
 adhesion, certainly contracted in childhood, proved ultimately harmless." 
 The late Dr. Sturges showed in these cases that acute carditis is present, 
 usually of rheumatic origin. Peck 2 has ably described in several such 
 cases a condition of " pericarditic pseudocirrhosis " resembling precisely 
 the mixed form of cirrhosis 3 of the liver, which is due to latent pericar- 
 ditis. The differential diagnosis is based upon : (1) Absence of etiologic 
 factor of cirrhosis ; (2) a history of pericarditis supported with the evi- 
 dences of it from physical signs. 
 
 i The American Journal of the Medical Sciences, 1895, p. 692. 
 2 Ibid., 1896, p. 221. 
 
 8 A case of pseudo-atrophic cirrhosis of the liver, secondary to adherent pericardium, is 
 reported by Dr. R. H. Babcock, of Chicago, in the Medical News, December 14, 1901, p. 924. 
 
140 TUBERCULOUS PERICARDITIS. 
 
 We should not ignore the difficulty of explaining why pericardial 
 adhesions are occasionally followed by such changes. Wells gives sev- 
 eral good aud sufficient reasons why tuberculous synechia is less to be 
 feared than that which occurs in purely rheumatic cases. Among these 
 may be regarded slowness of growth, no valvular defects, no toxemia 
 affecting heart muscle. Moreover, he states heart dilatation occurs in 
 rheumatism at period of inflammation or later, when effusion is being 
 absorbed. 
 
 In the latter instance, as I have already pointed out, the pericardium 
 becomes dilated and softened, and thus fails to give the heart proper 
 support. In addition to this, however, if the pericardium is attached to 
 the chest walls it simply cannot follow the heart, owing to mechanical 
 conditions. For this reason, again, the heart yields more and more to 
 internal pressure, and consequently becomes more and more dilated, 
 weak, inefficient, and ultimately powerless. 
 
 In these cases we often find beneath a very thick pericardium a con- 
 siderable growth of connective tissue, together with a deposit of fat in 
 the superficial parts of the heart muscle. 1 In rare instances are we able 
 to demonstrate the existence of gray tubercles in the myocardium. 
 Where caseous deposits are found at the autopsy they are more impor- 
 tant because they have penetrated the heart wall deeply, and in the 
 event of perforation they serve to explain the transport of numerous 
 bacilli in other organs and the signs of general miliary tuberculosis, 
 which are easily recognized, even during life. 
 
 The usual termination of tuberculous pericarditis is death. This 
 may be brought on directly by the recurrence of a large effusion, fre- 
 quently hemorrhagic, which repeated tapping has failed to relieve. Of 
 course at times the adhesions which have formed to chest walls, lungs, 
 and diaphragm seem greatly to shorten the duration of life ; but these 
 again may never occur, and the heart may simply float freely in the 
 fluid which surrounds it more or less on all sides. 2 Often, as I have 
 said, the fatal ending is immediately attributable not to the heart itself, 
 but to the general miliary tuberculosis of different viscera with which 
 the cardiac condition is associated. 
 
 Death may occur from an embolism, but this is extremely rare. 3 
 " Tuberculous pericarditis is generally unaccompanied by any symptoms 
 referable to the heart, and is almost always an autopsy finding." * With 
 this statement of Wells, corroborated by Osier, 5 judging by my two 
 recorded cases, I should be inclined to differ. 
 
 For the cases which are slowly and insidiously developed there is little 
 or no local treatment to be advocated. This is true of the cases which 
 
 1 Second case reported by me. 2 See my first case— pathologic report. 
 
 3 Case 8, reported by Wells. 4 Loc. cit, p. 1458. 
 
 6 Already cited. 
 
TUBERCULOUS PERICARDITIS. 141 
 
 terminate in synechia and where the symptoms are frequently very 
 obscure. The systolic retraction of the nipple in these instances is a 
 deceptive sign, as more than once I have been able to observe. In this 
 connection Lee Dickinson states we may have pulling in of lower ribs 
 with systole, but adds that cases with this indication are seldom avail- 
 able. The most characteristic of all indications " are rapid progress of 
 the case to the fatal end and the signal failure of all known means of 
 relief in heart disease." 1 
 
 Inasmuch as there is small effusion and no obvious inflammation, 
 these two conditions may not require active interference. In those 
 instances in which the onset of the disease is acute it is indicated at 
 first to limit the amount of inflammation. Personally, I favor the local 
 use of poultices or hot flannel stupes. To the former mustard may be 
 added ; the latter may be sprinkled with turpentine. Equal parts of 
 soap liniment and turpentine applied for several hours on warm flannel 
 are recommended. If cold be employed I much prefer Leiter's coil to 
 an ice-bag. The latter is difficult to keep in place and causes distress 
 from cold at times, which we cannot regulate easily. 2 A small quantity 
 of morphine hypodermically may be called for to allay pain. In the 
 cases that I have seen I have not thought the cautery or blisters were 
 required in the beginning of the attack. Later, I am confident, repeated 
 small fly blisters may limit the amount of the exudate formed. It is 
 also possible that an effusion already formed may thus be made to dis- 
 appear, in part or wholly, and more rapidly than it otherwise would. 
 Despite what has been said, it is far wiser in many cases not to attempt 
 to influence the pericardial condition by any local application. When- 
 ever the effusion becomes considerable or excessive, paracentesis should 
 be thought of. If the lips and fingers become cyanosed — if there is 
 marked dyspnoea, and weak, frequent, irregular pulse — prompt with- 
 drawal of fluid is necessary to preserve life. If, before paracentesis is 
 performed, the exploring needle shows the presence of pus, it is more 
 judicious, in many instances, to incise the sac freely and introduce a 
 drainage-tube. Of course, if the condition of the patient is imminent, 
 paracentesis may first be performed and subsequently the more radical 
 operation. 
 
 The position of the heart with respect to pericardial effusions is fre- 
 quently undetermined. In purulent fluids the heart is supported by or 
 floats upon the fluid, and is carried directly against the chest walls. 
 This has been proven experimentally. In fluids containing some blood, 
 or in pure serum, the heart is surrounded by fluid, as a rule, of which 
 the larger quantity is in the lower and left lateral portion of the peri- 
 cardial sac. 
 
 1 The American Journal of the Medical Sciences, 1896, p. 696. 
 
 2 Of course we can put a towel or flannel compress underneath. 
 
142 TUBERCULOUS PERICARDITIS. 
 
 Whenever puncture of the heart is indicated, some hesitancy arises 
 in performing the operation on account of the danger incident thereto. 
 There is risk of wounding the mammary artery, of entering the left 
 pleural cavity, of puncturing the liver, of wounding the peritoneum, or, 
 indeed, of going through the diaphragm. Perhaps the latter is of no 
 special moment, as it is the way by which entrance to the pericardium 
 is occasionally suggested or taken by the surgeon in a radical operation. 
 
 The classical site for aspiration of the pericardium may be regarded 
 as the left fifth interspace, near the sternal margin. 1 Other regions, 
 however, have been tried more or less successfully — i. e., beyond the left 
 nipple and near the outer line of cardiac dulness ; in the right fourth 
 intercostal space ; in the angle of the xiphoid cartilage and the margin 
 of the left costal arch. The right interspace is specially indicated by 
 Dr. Rotch, of Boston, in those cases where he has found dulness over 
 this area. 2 Dr. F. C. Shattuck, in his able paper before the Association 
 of American Physicians, Washington, 1897, has tried different points 
 for aspiration of pericardium, with satisfactory and sterile results. 
 
 On one occasion where a small quantity of fluid was withdrawn, later 
 the autopsy showed at least one pint of fluid in the sac. It may be 
 inferred in such cases that the fluid thus discovered was produced 
 during the agony or after death. It seems to me more probable that it 
 was in the pericardial sac during life, but could not be aspirated on 
 account of the position of the heart and the wrong point of puncture. 
 In this connection I am glad to be able to refer to a recent able article 
 by Dr. O. Damsch, 3 which settles definitely, it may be, most points 
 hitherto questionable about the position of the heart, that of the effu- 
 sions, and the point where we should always try paracentesis. Dr. 
 Damsch made injections experimentally into the pericardium, the sub- 
 ject being in the upright position, for the purpose of determining the 
 position assumed by the pericardial exudate. Small amounts, he found, 
 collect in the lower and anterolateral portions of the pericardium, caus- 
 ing approximation of the right anterior portion of the pericardium to 
 the chest wall. The heart, when of normal size, was always found 
 pressed against the posterior portion of the pericardium, the fluid occu- 
 pying the anterior portion. In cases in which the heart was hyper- 
 trophied it was pressed upward and anteriorly, Its increased size, 
 according to Damsch, causes it to fill the whole space between the 
 anterior and posterior chest walls, and therefore, since the fluid collects 
 in the lower part (pericardium), the heart must be pressed upward. 
 
 1 Roberts states (Trans. Surg. Assoc.) that this point of election " will not assure safety to 
 the pleura." 
 
 2 The clinical conclusion from Damsch's experiments was that "first sign of pericardial 
 effusion would be an area of dulness in heart-liver angle, as taught by Rotch." (Lot. cit.) 
 
 3 Gould's Year-book, 1901, pp. 178, 179. 
 
TUBERCULOUS PERICARDITIS. 143 
 
 " From his experiments he decides that the best position for puncture is 
 well down toward the lower part of the pericardium." He also decides 
 that puncture in the fifth or sixth intercostal space (left) next to the 
 sternum, directing the trocar somewhat inward, is the safest method and 
 location of paracentesis. Thus performed there is no danger of wound- 
 ing either heart or pleura. If the heart is normal the fluid is in front 
 of it and at lower part of pericardium ; if the heart is enlarged, which 
 it usually is, it is floated upward and out of danger. 
 
 Aspiration of the pericardium relieves, without doubt, for a while 
 imminent symptoms, and, as an operation of urgency, should be em- 
 ployed unquestionably. When we come to consider it as a curative 
 means it is of less value. I have seen the fluid recur several times 
 after it has been removed, and that, too, in a relatively short period. 
 This statement is true of instances in which the pericarditis, either at 
 that time or subsequently, was known to be tuberculous. One is thus 
 led to ask whether in these instances it is not preferable to perform a 
 radical operation with proper surgical technic and thorough drainage 
 of the pericardium. In purulent cases the general consensus of good 
 surgical judgment is to that effect. In tubercular cases where the 
 effusion is not purulent it may be also a wiser procedure than simple 
 puncture, because through the open wound the finger may be intro- 
 duced and large masses of fibrin extracted. These masses, if allowed to 
 remain in situ, inevitably delay cure by allowing fluid to re-form rapidly. 
 After a reproduction of fluid on one or several occasions, adhesive peri- 
 carditis may and does develop, and, sooner or later, we have to do with 
 a seriously crippled heart. There might be a chance of obviating this 
 by means of the canula left in place, and the use through it of some 
 form of alterative injection. Rendu 1 reports such a case of cured 
 tuberculous pericarditis. The modifying injecting fluid employed by 
 Rendu was a solution of pure camphorated naphtol. 
 
 What is true in cases where effusion has been withdrawn as regards 
 some of the results to heart fibre is true where we leave the fluid in the 
 pericardial sac and do not attempt to remove it. By and by underneath 
 the thickened layer there comes a large layer of fat. This fat finally 
 penetrates the heart wall between the muscular fibres, and, in connection 
 with a deposit also of cellular tissue, leads to fatty degeneration of the 
 heart structure, and later, perhaps, to combined fibroid changes. 
 
 As regards serous effusions, even though large in amount, such as we 
 meet with as a complication, especially of acute articular rheumatism 
 and occasionally in nephritis, these rarely require, puncture, in my 
 judgment. Whenever the indication arises, unless the condition be very 
 
 1 Journal of the American Medical Association, 1901, p. 1432. Also, Bull, de la Soc. de 
 H3pitaux de Paris, March 21, 1901. 
 
144 TUBERCULOUS PERICARDITIS. 
 
 imminent, I am of the opinion that one or a succession of fly blisters over 
 or near the heart will accomplish all that is urgently required. It is 
 not essentia], moreover, that much fluid be removed from the pericar- 
 dium in these cases so as to promote absorption ; a small quantity is 
 sufficient. The proof of this is that often after aspiration of the peri- 
 cardium, where very little fluid has been actually removed, a notably 
 beneficial effect quickly follows. The same thing results from a severe 
 counterirritant or revulsive. How this acts (blister) 1 I am not quite 
 sure. Evidently there is no immediate vascular connection between the 
 skin in the precordial region and the heart itself, and for this reason it 
 would seem as though the blister would do as much good were it placed 
 over a region far removed. Certainly, if mere reflex action comes into 
 play it is possible. And yet, somehow or other, I am a believer in its 
 good effects applied over the precordium, and I do know that revulsion, 
 irritation, or heat locally over the heart is of great practical value in 
 adding to its power. I can readily conclude, therefore, that wherever 
 effusion in large amount is partly passive, increased heart action may 
 be remedial in a very distinct and rapid manner. 
 
 With respect to the operation of paracentesis versus the use of coun- 
 terirritation in those cases where the effusion is limited and probably 
 serous, we should always have in view the possibility of change to a 
 purulent effusion caused by the little operation itself, especially if per- 
 formed with the ordinary trocar and canula. With proper aseptic pre- 
 cautions and the use of the aspirator, this to-day may be regarded as a 
 negligible quantity. Moreover, it is known that but one case has 
 resulted fatally following the puncture. " With this exception all the 
 patients were greatly relieved by the removal even of a small amount of 
 fluid, and many recovered completely who probably would have died if 
 the operation had not been performed." 2 
 
 In purely purulent effusions it is now generally admitted that surgery 
 with open wound, with or without drainage, should alone be considered. 
 Porter's case 3 and others still prove this. Only lately, for example, 
 H. Lilienthal has had a successful radical operation in a case of purulent 
 pericarditis. Here aspiration had proved insufficient. In Lilienthal's 
 case a portion of the fifth left costal cartilage was resected close to the 
 sternum under local anesthesia. Forty ounces of fluid were removed 
 from the pericardial sac. 4 
 
 In another case, reported by Ogle and Allingham, the pericardium 
 was opened, a large quantity of pus removed, and the pericardium 
 
 1 Dr. Shattuck never uses blisters. Drs. Tyson and Rotch would not let them go. 
 s The American Journal of the Medical Sciences, 1897, p. 458. 
 
 3 The only case ever treated by incision in Massachusetts General Hospital (F. C. S.). Boston 
 Medical and Surgical Journal, May 6, 1897, p. 438. 
 
 4 New York Medical Record, November 25, 1900. 
 
TUBERCULOUS PERICARDITIS. 145 
 
 cleansed, without interference of the action of the heart and with 
 decided benefit to the patient. It was shown in this instance that the 
 heart can be handled without harm. It is therefore advisable to treat 
 these cases precisely as we would an empyema. Indeed, the operation 
 is more indicated than that of empyema, because the walls of the cavity 
 are better able to contract and finally lead to complete obliteration. We 
 know the outcome in empyema, where, to reach the best obtainable 
 result, portions of several ribs must often be resected. Even then we 
 have to deplore many incomplete successes. 
 
 Finally, in the operation by opening and drainage we have really the 
 only legitimate hope of entire recovery. No one has insisted upon this 
 operation more strenuously than Dr. J. B. Roberts since 1876. In a 
 late paper he reiterates his findings. Very properly he says, " the 
 diagnosis of the purulent character of the effusion was only determined 
 by exploratory puncture." 1 And "this should be done at the upper 
 part of the left xiphoid fossa close to the top of the angle between the 
 seventh cartilage and the xiphoid cartilage." 2 
 
 " The prognosis is good," says Dr. Roberts, " in pericardotomy for 
 pyopericardium. In a table of 26 collected cases 10 recovered and 16 
 deaths were shown. This gave a percentage of recovery of 38.4. Of 
 the fatal cases at least 9 were septic, and all the others who died had 
 complicated lesions, such as pleuritis, or pulmonary, cardiac, or renal 
 lesions." 3 
 
 " The results obtained by incision and drainage in tubercular peri- 
 tonitis suggest that drainage in tuberculous pericarditis may lead to a 
 permanent cure. The ease with which the pericardium can be irrigated 
 with solutions of iodoform would seemingly add to this probability of 
 success." i 
 
 After analyzing different cases, Roberts writes: " These observations 
 and other reported cases not here mentioned have almost convinced me 
 that incision is better than aspiration, even in cases not supposed to be 
 purulent. It establishes diagnosis in dubious cases, avoids cardiac 
 injury, saves the pleura from puncture, affords complete evacuation 
 of effusion, permits extraction of thick pus and membranous lymph, 
 and gives opportunity for disinfection of the sac when that is neces- 
 sary." 5 
 
 Porter cites one successful case of incision in serous pericarditis where 
 puncture failed to relieve. 6 
 
 Personally, so far as tuberculous cases are concerned, I agree with 
 Dr. Roberts. Ordinarily, in cases of simple serous effusion of other 
 provenance I do not believe incision is called for, and if any operative 
 
 1 Boston Medical and Surgical Journal, May 27, 1897, p. 522. 2 Loc. cit. 
 
 8 Loc. cit. * Transactions of the American Surgical Association, 1897, p. 108. 
 
 6 Loc. cit. • Transactions of the Surgical Association, vol. xv. 
 
146 TUBERCULOUS PERICARDITIS. 
 
 interference is required I still prefer paracentesis. If irrigation be 
 employed as an adjunct in incision the outflow of fluid must be unim- 
 peded, or death may rapidly result from it. 
 
 In regard to the technic, it is not necessary to say more than to point 
 out that the best operation is the one usually which permits best drainage 
 in a given case. In one instance it may indicate resection of the fourth 
 or fifth rib on the left side; in another the pericardium should be opened 
 from below and through the insertion of the diaphragm near the central 
 tendon. 
 
 It should be remembered, in my judgment, that the question of radical 
 operation for pericarditis with effusion is different in one very important 
 particular from that of pleurisy with effusion. There are two lungs ; 
 there is only one heart. A patient may do fairly well a long time with 
 pleuritic adhesions, a retracted chest wall, and an atelectatic and fibroid 
 lung. No patient will continue long to be in any degree comfortable or 
 active who has adhesive pericarditis as a sequela of large and long-con- 
 tinued effusion, with the pathologic changes of heart walls which inva- 
 riably follow sooner or later. 
 
 To those who have had small clinical experience with these cases, and 
 who may be led to believe that the liability of heart puncture is slight, 
 I would point out that the anatomical relations of the pericardial sac, 
 despite Dr. Damsch's researches with the chest walls and left pleura, in 
 many instances are very perplexing and variable. As to the differential 
 diagnosis of pericardial effusion with a heart merely enlarged, while this 
 is often very simple and requires no great medical acumen, there are 
 occasions when the most careful use of physical methods of exploration 
 will leave one in a state of great uncertainty. Again, I have had to do 
 with cases where I was confident there was a large effusion and no risk 
 in introducing a small trocar connected with the aspirator. Unfortu- 
 nately, my diagnosis was incorrect, manifestly on one occasion, and 
 instead of withdrawing fluid from the pericardium my aspirating needle 
 penetrated the heart wall. This was obvious by reason of the fixed 
 position and special movements transmitted to the canula when the 
 trocar was withdrawn. In this instance no great or immediate harm 
 resulted. Still, it is an accident to be avoided, as far as possible, by 
 great care and attention. 
 
 Orphuls reports a case where, at the autopsy, the end of a trocar 
 needle was found in the scar tissue at the upper portion of the interven- 
 tricular septum. This needle probably broke off in an exploration or 
 in a previous operation of paracentesis. 1 Loison 2 affirms, also, that in 
 wounds of the heart and pericardium the " prognosis is not always 
 
 1 British Medical Journal, January 27, 1900. 
 
 2 The American Journal of the Medical Sciences, 1900, p. 218. 
 
TUBERCULOUS PERICARDITIS. 147 
 
 grave." The judgment is strengthened by the statistics collected both 
 by Fischer and himself. On the other hand, Rotch has "known of a 
 case where pricking the heart with an aspirator needle caused sudden 
 death," and Janeway one where the aspirating needle tore the heart, 
 causing death. 
 
 Formerly, so as to avoid just such mishaps, I had constructed for 
 myself a modified Roberts canula. 1 This is a very good instrument 
 when kept in proper order. It is a little complicated, however, and 
 requires to be looked after. All that precedes acquires additional inter- 
 est, if we recognize, as many do, that the ordinary medicinal remedies 
 as applied to the treatment of pericarditis with effusion (especially the 
 tuberculous form) have very little value. 
 
 I am not aware, once pericarditis has become developed, that any 
 remedy given internally abridges its duration or changes its course very 
 perceptibly. I acknowledge, of course, in a few instances, that the 
 heart needs special stimulation in view of the failure that may come on 
 suddenly or by degrees. The alkaline treatment may prove very useful 
 in giving strength to cardiac contraction — more, indeed, than the use of 
 digitalis. This would be in accord with the experiments of Gaskell. 2 
 I also know that in a few — a very few sthenic cases — aconite may be 
 indicated for a short time to lower blood tension and decrease the rapidity 
 of the pulse ; but that is about all there is to do in the acute stage by 
 way of the mouth. Locally, as I have already pointed out, the ice-bag 
 or poultices, blood-letting (leeches and cups), are useful where there is 
 pain or great increase of heart action. Beyond some degree of soothing 
 or quieting thus produced, we should not count upon a great return. 
 The prophylactic measures to be employed have to do solely, it seems to 
 me, with the efficient causes of tuberculous pericarditis which prevail, 
 be it possibly pleurisy, pneumonia, sepsis of some sort, or mere exposure, 
 fatigue, or debauch. 
 
 As we know already, tuberculous pericarditis may show itself when 
 we have had little or no suspicion of its presence. It may also be 
 ushered in with so few obvious symptoms or signs, local or general, that 
 except in an accidental way it is not discovered during life. There are 
 many examples, indeed, where the presence of the disease was ignored 
 during life, and only ultimately revealed by the findings at the autopsy. 
 
 Appended is an abstract of the history of my second case : 
 
 History of Case of Tuberculous Pericarditis (No. 2). B. F., married, 
 a hod- carrier, born in the United States, aged thirty-eight years, was 
 admitted to St. Luke's Hospital under my care, March 19, 1901. 
 Family and personal history negative, save that he was a somewhat 
 
 1 The Medical Record, March 29, 1884, p. 361. 
 
 2 The American Journal of the Medical Sciences, 1896, p. 696. 
 
148 TUBERCULOUS PERICARDITIS. 
 
 excessive drinker of beer and whiskey. Present illness began four 
 months ago, after a debauch, with pain in his right side. No cough, 
 chills, or vomiting. The pain in the side lasted a month, when he began 
 to cough, expectorated blood-stained mucus, had some fever, with after- 
 noon exacerbations, and became weaker. Two weeks ago pain in the 
 precordial region, with palpitations, developed ; also at times dyspnoea. 
 No swelling of the feet. 
 
 Physical examination shows marked increase of cardiac dulness, rapid 
 heart action, and a high-pitched systolic murmur, heard between the 
 nipple (left) line and sternum. Thoracentesis gave serous fluid in right 
 pleural cavity. Temperature, 99.3° F. ; pulse, 100 ; respiration, 49. 
 Urine, acid, 1020, no sugar, no albumin, few leukocytes. No tubercle 
 in sputum. 
 
 X-ray examination shows shadow corresponding to line of cardiac- 
 percussion dulness. 
 
 Microscopic examination of blood negative ; also examination of eyes 
 negative. 
 
 April 25th. Guinea-pig inoculated with fluid from right pleura. On 
 May 19th tubercle found in cheesy pus from enlarged lumbar glands of 
 guinea-pig. 
 
 May 26th. Patient paralyzed on right side. Soon became comatose 
 and died the same day. During sojourn in the hospital the patient was 
 feverish, with pronounced irregular rise in the afternoon. 
 
 Autopsy, made by Dr. N. E. Ditman, resident pathologist, showed 
 much thickened pericardium ; sac contained eight ounces of yellow,, 
 turbid fluid. Heart enlarged, muscle pale, and covered by a layer of 
 subpericardial fat ; valves normal, save a slight atheroma of one flap of 
 mitral. Dungs, liver, spleen, meninges, and peritoneum showed dissemi- 
 nated miliary tubercles. 
 
 Microscopic examination showed cheesy degeneration and numerous 
 giant cells throughout the pericardium. In the layer of fat over the 
 heart and beneath the pericardium were numerous small masses of small 
 round cells, and in each mass giant cells were present. The heart 
 muscle, superficially, was infiltrated with fat. More deeply there was 
 a moderate small round-cell infiltration between the muscle bundles, and 
 in places the latter are separated by connective tissue ; connective tissue 
 of bloodvessel walls increased in amount. 
 
A STUDY OF SOME C1RRHOSES OF THE LIVER. 
 
 No doabt the majority of practitioners believe they know pretty 
 well about cirrhosis of the liver. It is a common affection, particularly 
 in hospitals and dispensaries. In its advanced stages it is readily diag- 
 nosed, as a rule. 
 
 In regard to its prognosis and treatment : These appear relatively 
 simple in that formerly at least it was assumed by very many that we 
 had to do with a fatal complaint ; and as for remedial measures, they 
 resolved themselves into few, among which paracentesis at the last 
 stage only was imperative, mainly to relieve distress. How far such 
 notions to-day are removed from truth I shall endeavor to show later. 
 
 That the liver is a difficult organ to study and know accurately 
 few will deny whose opportunities and mental make-up prove them 
 competent observers. As compared with other abdominal or thoracic 
 organs, where does it stand ? The lungs can be inspected, palpated, 
 percussed, auscultated, and in a way measured. So, perhaps, can the 
 liver ; but in the former case we seem to be in more accurate touch 
 latterly by reason of sputa examinations under the microscope and 
 inoculation experiments. The heart and its disorders have been the 
 source of so many investigations in the physiological laboratory, so 
 many accurate clinical observations in the office and the class room, 
 hospitals, and dispensaries— everywhere and at all times — that little 
 new may be added. With the advent of physiological chemistry, the 
 use of the microscope, and the opportunity, daily or hourly almost, of 
 knowing precisely what the urine shows, the kidneys as organs are very 
 clear to us. With the liver, on the contrary, much seems still conjec- 
 ture and hypothesis. We speak of its torpidity, engorgement, anaemia, 
 its functional derangements, its organic lesions, with glibness at times ; 
 and yet there is much that is obscure about its functions, healthy and 
 morbid, that is by no means evident, and about which there are very 
 honest and almost irreconcilable differences. 
 
 In this connection, only very lately, Dr. Goodhart writes : " The 
 largest organ of the body, its imports and exports must be enormous, 
 and from the familiar way in which it is spoken of there cannot be 
 a man in the whole world who does not think he knows all about it. 
 But what are the facts ? We know something about the physiology 
 of the liver ; but this knowledge has been mostly obtained by experi- 
 mentation on the lower animals, by observations that occasional cases 
 
150 CIRRHOSES OF THE LIVER. 
 
 of disease afford us, and by certain inferences that we draw — very- 
 much at second hand — from the changes produced by disease in the 
 organ. But all these things — valuable as they are, and without which 
 where we should be I do not know — yet are very far from giving us 
 that real and intimate knowledge of the living organ that we require 
 to enable us to treat its diseases." 1 
 
 Should this not be adequate reason why we approach the study of 
 the cirrhoses with much diffidence and full recognition of our deficien- 
 cies, even in the role of an upright reporter ? " Good men and true " 
 have essayed this work faithfully in the past, and told us many things 
 we should know. A great deal more is required, much research remains 
 to be done, and only by degrees may we legitimately hope to secure 
 truth — entire and with full details. 
 
 In what relates to the cirrhoses there are many undetermined ques- 
 tions. The views ordinarily held are not entirely correct. In the first 
 place, the clinical facts, the more we become conversant with them, do 
 not justify invariably the gloomy prognosis of these affections which 
 has been entertained. Instead of separating with discrimination, there 
 has been confusion, because all forms of the disease have been thrown 
 together and included as one. In fact, here as elsewhere, the work of 
 the dead-house has reigned supreme for a time, and the close watching 
 of patients during life has been deemed of lesser value, when it should 
 always, as I believe, be the first thought of every good physician. How, 
 indeed, can we treat a patient properly unless we know just what 
 symptoms he presents during life and in what manner and to what 
 degree function was disturbed ? Everyone who has grown gray in 
 harness and whose experience has widened and deepened knows that 
 the morgue and the laboratory by themselves ignore too much and too 
 often the intricate and obscure of our economy in a dynamic sense, 
 and hence must be always controlled, as it were, from the horse-sense 
 point of view of even the humbler humdrum daily worker at the bed- 
 side. 2 
 
 There are different forms and degrees of cirrhosis. Not all at once 
 and every time does the final atrophic stage, with its irremediable 
 anatomical conditions and its absolutely gloomy horoscope, show itself. 
 This form is slow and insidious of development. At first it is not 
 recognized ; there are few or no symptoms we can attach to it. At 
 best we can only be suspicious. 3 If we have to do with a chronically 
 hard drinker of beer or spirits, of course, we think of the liver and 
 
 1 British Medical Journal, August 3, 1901, p. 251. 
 
 2 Vide Andrew Clark, British Medical Journal, February 3, 1883, p. 191 : " Address on Clini- 
 cal Investigation before the Clinical Society of London." 
 
 3 In writing of early stages of hepatic cirrhosis, Billings claims there is a relatively large 
 number of patients whose symptoms are those of neurasthenia, myalgia, mononeuritis, or 
 gastro-intestinal disturbance.— Medical News, July 26, 1902, p. 167. 
 
CIRRHOSES OF THE LIVER. 151 
 
 fibroid changes ; and then if there be palpitations of the heart, evidences 
 of dyspepsia, vascular stigmata on the face, corpulency, and a some- 
 what enlarged liver we cry a halt to bad habits, and the outlook may 
 be sombre. On the same lines, if we find loss of strength, inap- 
 petence, and a failure of nutrition, as shown by loss of weight, even 
 though the liver be of normal size apparently, we cannot avoid some- 
 what gloomy forebodings unless we are able soou to control habits and 
 regimen. But are we sure — may we be reasonably certain — with such 
 vague characters that we shall even later be able to fix an absolute 
 and correct diagnosis ? The answer — the only one — must be negative. 
 The sooner the better for every medical student to know that disease 
 does not run closely at any time along so-called prescribed lines. It 
 varies, it differs ; one day we see certain forms of disease, another day 
 it is just the contrary. All cases are in a certain sense individual, 
 personal. There is nothing wholly general and all-absorbing about 
 any one instance. Take, for example, the abdominal effusion in cir- 
 rhosis — the ascites which in the later stages is so striking, so character- 
 istic, so grave of import in the eyes of many that it seems like to a 
 funeral knell in its fatality. Is it so ? May it not appear soon, and 
 in its earlier stages may it not be treated wisely and advantageously ? 
 And may not a patient do well for a long while, thus treated ? And 
 why is this ? May not very many of the liver cells still be function- 
 ally healthy, quite capable of carrying on good nutrition ? Is not 
 fibrous growth in the liver usually slow ? Does it not leave many 
 lobules untouched for many a day by its contracting power, and other- 
 wise in what degree is it really pernicious? These and other queries 
 immediately arise to one's mind. It is, moreover, a fact of daily ex- 
 perience almost to have patients come to our office or to out-door clinics 
 in whom ascites is undetermined. We are unable to affirm positively 
 that it exists. And this is true not for one examination only, but for 
 many. Days, months, and even years elapse with some patients before 
 we can say convincedly this is or this is not a case of hepatic cirrhosis. 
 The three principal forms of cirrhosis which are recognized by 
 writers are (1) atrophic, (2) hypertrophic, (3) syphilitic. Besides these 
 there are so-called minor, even undetermined, forms. Usually the 
 latter are due to passive congestion, brought on by pressure from 
 neighboring tumors or indicative of some chronic disturbance of heart 
 power, structure, or action. In these instances, especially where the 
 heart is the primary cause, the abdominal ascites is merely a symptom 
 which is part of a general anasarca. It may be, however, that the 
 ascites has something special in it ; it may stand by itself, as it were, 
 so far as effusion is concerned in the serous cavities. Then we have 
 to do with an expression of cardiac inefficiency accompanied by one of 
 the known effects of portal obstruction due to fibrosis around the vessels 
 
152 CIRRHOSES OF THE LIVER. 
 
 of the liver. In these cases we should look rather for hypertrophy than 
 atrophy. The liver is enlarged and engorged. It is filled with blood 
 from overcongestion. There may or may not be already marked fatty 
 change, and thus, instead of the dense, hard, tough liver with sharp 
 lower margin, which is said to characterize the cirrhotic liver, we may 
 have a greasy, rather soft structure, which leaves the impress of the 
 finger upon its surface when we press with even very moderate force. 
 While, then, it may be admitted, and is certainly true with limitations, 
 that all three forms of cirrhosis of the liver are characterized by in- 
 crease of fibrous tissue, which penetrates its structure and distributes 
 in somewhat different ways along the branches of the interstitial tree, 
 it is also true that these forms are all different in many particulars. 
 
 Their pathology, to begin with, is not the same. In one form — the 
 hypertrophic — the fibrous tissue is finer, less formed, accompanied by 
 a cellular growth, and runs along the smaller branches interstitially. 
 In the atrophic form this fibrous tissue is coarser, better formed, shows 
 greater tendency to contract upon and disorganize liver cells, extends 
 along larger branches of the interstitial tree, and is not accompanied 
 -by cellular growth to the same degree at all. 
 
 In connection with the increase of connective tissue it has been 
 proven experimentally that the action of alcohol on the liver of 
 animals is also to cause granular and fatty degeneration of the liver 
 cells. According to Vaughan, the increase of the connective tissue 
 is small in amount, and only reported by some observers. Vaughan 
 concludes that " the connective tissue changes are subsequent to and 
 dependent upon alteration in the hepatic cells." 1 Later on he writes 
 that with the clinical and experimental evidence hitherto obtained we 
 are justified in believing " that in alcoholic cirrhosis the pathological 
 changes begin in the hepatic cells." 
 
 From what has been said concerning the pathology and etiology of 
 atrophic and hypertrophic cirrhosis it has been shown that the two 
 forms may exist as types. They may also be present combined, as it 
 were, in the same individual and exist as one disease. The atrophic 
 form is clearly due, as a rule, to alcohol ; the hypertrophic to infection 
 (Vaughan) ; but the infection may precede or follow the toxic poison- 
 ing, and the result is a mixed form of cirrhosis. These forms, both 
 clinically and at the autopsy, are very difficult of precise diagnosis, so 
 intimately and curiously combined are their symptoms or lesions. 2 
 
 1 Journal of American Medical Association, October 5, 1901, pp. 878, 879. 
 
 2 In a patient I saw last summer, who subsequently died, the liver was stated during life to 
 be much enlarged by several very competent observers— both surgeons and physicians. I was 
 able to satisfy myself after death, by intra-abdominal digital exploration, that the liver was 
 not notably enlarged. I was also convinced that an intra-abdominal mass, in close juxtaposi- 
 tion with the lower margin of the liver, gave rise to an error of diagnosis in this regard, 
 although the case was proven not to be one of cirrhosis of the liver. 
 
CIERHOSES OF THE LIVER. 153 
 
 la the syphilitic cirrhosis we have those broad bands of fibrous tissue 
 which penetrate between the lobules and draw the liver down near the 
 surface in such manner as to leave the puckered, scarred appearance, 
 with bossy, prominent, irregular masses between which are so charac- 
 teristic. 
 
 As to the course and clinical symptoms : These, we shall see, differ 
 widely and obviously in many ways. In atrophic cirrhosis, for exam- 
 ple, the main distinguishing clinical feature, as we could almost 
 premise from its pathology, is the evidence of marked portal obstruc- 
 tion — at least this is true almost as soon as the disease is clearly deter- 
 mined. Hence arises the abdominal effusion, and with this most 
 significant and almost portentous sign we have hemorrhages from the 
 stomach and bowels. Sometimes these are small and infrequent, and 
 give no great and immediate alarm if their quantity alone is consid- 
 ered ; but considered from the point of view of their evident causation, 
 great apprehension is invariably excited, and justly so. Shortly we 
 may have, and do often, those abundant and depressing blood losses 
 so difficult to arrest, and which point to the urgent necessity, and none 
 too soon, of employing all rationally known measures to ease up an 
 obviously crippled organ and to restore falling strength. How unfor- 
 tunate it is in such cases if the somewhat too enthusiastic surgeon finds 
 indications for abdominal exploration or an operation for internal 
 hemorrhoids ! Jaundice is a rare sign in these cases 1 — at least real 
 jaundice, with urine loaded with bile pigment and acholic stools. Of 
 course, the dull, earthy hue of the skin and the subicteric tint of 
 the sclerotics are frequent phenomena which serve in a measure to fix 
 our diagnosis. Sometimes " adhesive pyelophlebitis closely resembles 
 the atrophic form of interstitial hepatitis. The rapidity with which 
 the peritoneal effusion reforms after tapping is an important diagnostic 
 sign." 2 
 
 These cases of atrophic cirrhosis in reality are long as to duration. 
 They appear short merely because they are unrecognized prior to the 
 advent of the ascites, and then the inevitably fatal termination seems 
 to stand out imminently, since a few months or a briefer period may 
 bring about a fatal ending of the case. 
 
 The first and imperative thing to do 'with these patients is to lay 
 down the law which forbids alcoholic stimulation in any form, because, 
 as we know, in the chronic irritation thus produced we find the imme- 
 diate and efficient cause of the majority of such cases. Of course, 
 there are degrees of injurious action. The man who has drunk heavy 
 
 1 Where fatty degeneration and cirrhosis coexist profound, persistent jaundice is less infre- 
 quent. A patient thus affected, as shown by the autopsy, died in one of my wards at St. Luke's 
 Hospital May 8, 1902. 
 
 3 James H. Wilson, Medical Record, December 7, 1901, p. 909. 
 
 11 
 
154 CIRRHOSES OF THE LIVER. 
 
 beers for a long while and in large quantities, combined, it may be 
 at times, with daily potations of spirits undiluted and containing fusel 
 oil, is the worst type with which we have to do. Such an one is the 
 longshoreman, hodcarrier, and other laboring man, or the chronic 
 loafer who comes to our out-door clinics or to our hospital ward, when, 
 on investigation, we find the contracted, small hobnailed liver, which 
 shows the condition of multilobular cirrhosis and also many accom- 
 panying pathological changes. The spleen and pancreas are often 
 hard and functionally decrepit, the kidneys show marked interstitial 
 changes, the stomach is thickened, atrophied, and congested ; but, 
 above all, the heart is weak, flabby, degenerated. Fibrous myocarditis 
 is sometimes made out at the autopsy ; more frequently we have more or 
 less fatty change, apparent to the eye and corroborated with the micro- 
 scope. The general vascular system does not escape, and capillary 
 arteriofibrosis has run its course, so that there is scarcely a sound 
 arterial coat to be found, no matter what organ we turn to. This is, in- 
 deed, a gloomy and, alas ! too true a picture. Alongside, fortunately, 
 we have another far more hopeful. The man-about-town, the broker, the 
 business man — even the lawyer and the not too wise physician — whose 
 drinking consists in two or three or more " Manhattan " or " Mar- 
 tigny " cocktails every day, taken upon an empty stomach and as " a 
 pick-me-up," as the saying goes ; the genial, pleasant fellow who gives 
 himself a rest of an evening, and who frequents the club and the 
 billiard-room, and who before the evening is gone has consumed several 
 drinks of "rye" or "Scotch" or "unsweetened," is also an apt 
 candidate for admission among the cirrhoses of the atrophic order. 
 Fortunately, such an one drinks "good spirits, as a rule, in the sense 
 that it is relatively pure and unadulterated. Moreover, his food is well 
 cooked and assimilable. He bathes, and is therefore cleanly and has an 
 active skin ; and with a healthier body, perhaps, to start with he does not 
 suffer so soon or so hopelessly as the poor chap I have previously con- 
 sidered. Moreover, when the first premonitory signs of disease occur, 
 if he be even moderately wise, he consults his family physician, when 
 I would fain believe he secures a mental and moral shaking up, with 
 which a little useful medicine added thereto allows him to guard more 
 carefully his still useful liver cells, and gives declared fibrosis an 
 opportunity to cease development and extension for a time. 
 
 Without going further in this description I trust I have been able 
 to show and bring home to my readers what they all know, what they 
 all feel and see around them every day. Turn, now, to our hyper- 
 trophic form of cirrhosis, and what may we note ? Here, instead of 
 atrophy and contracture and loss of size, we have enlargement and 
 increase of weight. In addition, there is to be found a singular devel- 
 opment of new biliary canaliculi on the periphery of the lobules, 
 
CIRRHOSES OF THE LIVER. 155 
 
 which is so distinctly shown in sections for microscopic insight. This 
 latter division is the one so ably described by Hanot, Charcot, and 
 other French writers, and about which there is such wide divergence of 
 opinion elsewhere. Suffice it to add that in typical forms these must 
 be very rare, infrequent cases. For my own part, I do not recall to 
 have seen and observed a typical one — at all events, not one where 
 the post-mortem researches justified altogether a previous clinical diag 
 nosis. In the hypertrophic cirrhosis of the sort we do see from time 
 to time the fibrosis as it extends into the liver seems to mark for its 
 own a few cells here and there throughout the structure, or certain 
 individual lobules. In this hypertrophic form ascites does not often 
 occur, nor should we expect it if we pay due regard to the special char- 
 acters of the fibrosis formation. Jaundice, on the contrary, is a marked 
 and almost omnipresent symptom ; and it is the real jaundice — not the 
 aborted state, so to speak — to which I have referred in the atrophic 
 form of cirrhosis, i. e., icteroid hue. 
 
 Like to atrophic cirrhosis, haemateniesis is not infrequent, and, when 
 it occurs, abundant and very threatening. Many of these hemorrhages 
 in cirrhosis originate at the lower end of the oesophagus. They are 
 often confounded with hemorrhages which come from ulcer of the 
 stomach. 1 In either case, but especially the former, Ave should be 
 very chary about the introduction of a stomach-tube, as a dangerous 
 or even fatal loss of blood might take place immediately. With the 
 hemorrhage from the oesophagus or stomach we see developed many 
 acute symptoms. There is fever, and often the temperature ranges 
 high. There is delirium of an active kind, pointing to a toxaemia and 
 blood infection. "Chills and sweating are not common" in the 
 hypertrophic form of interstitial hepatitis, ' ' thus serving to differen- 
 tiate it from impacted gallstones." (Wilson.) 
 
 Later the patient may relapse into coma from which there is no 
 awakening. Before these symptoms of delirium and coma become 
 manifest we usually have several repeated intermittent attacks of pain, 
 with fever. The pain is localized over the hypochondrium, and the 
 liver is tender. 
 
 In these particulars we have an approach to the syphilitic form, and 
 except for the history, the different physical signs, and other symptoms, 
 we might have a difficult diagnosis ; but this is not true for the careful 
 
 1 According to Knapp (Medical Record, March 1, 1902, p. 334) these hemorrhages are some- 
 times erroneously "diagnosed as pulmonary tuberculosis," when they should be considered 
 " cases of ulcer of the oesophagus." 
 
 According to Bouchard (Revue de M6decine, October, 1902) hemorrhages in cirrhosis, 
 which occur outside the territory of the portal vein, are in relation with pre-existing arterial 
 lesions, affecting various organs, and do not depend upon abdominal plethora. The arterial 
 lesions are chronic degenerative changes probably due to arterio-sclerosis. — Boston Medical 
 and Surgical Journal, September 11, 1902. 
 
156 CIRRHOSES OF THE LIVEE. 
 
 diagnostician, who also considers the ordinarily chronic course of the 
 disease. 
 
 As to causation, it is obscure. Frequently the spleen also being 
 enlarged a malarial origin is suspected. There are too few observa- 
 tions accurately made in which the plasmodium has been discovered 
 to altogether justify this opinion. I rather believe that alcohol 
 is here again a more probable and efficient factor in bringing on this 
 change in liver structure. One statement would seem to be borne out 
 by facts that we do know, and it is that the obstruction of the bile 
 ducts by fibrous tissue seems to account for the genesis of the acute 
 symptoms which mark the course of the disease and point to inflam- 
 matory conditions, more or less lasting. According to some authors, 
 such inflammatory conditions are wholly ignored, and they affirm that 
 an infective process is the sole, undeniable cause of hypertrophic cir- 
 rhosis. In this conection Vaughan 1 writes : " With our present knowl- 
 edge it must be attributed in all cases to infection." If this be ad- 
 mitted, pathologically, it may be stated that " the epithelium of the 
 gall ducts is the site of the primary involvement." (Vaughan.) 
 
 In the syphilitic liver we find marked induration, at times fairly 
 recognizable by our tactile sensations. The liver itself is, as a rule, 
 larger than uormal. This is not an invariable rule, and just the con- 
 trary may be found, no doubt, in those instances where the fibrous 
 contracting bands are broad and numerous. The gummata on the 
 surface of the liver when they exist are often easily recognizable. Of 
 course, we may confound them with malignant nodules on the one hand 
 or perhaps the hobnailed condition of atrophic cirrhosis on the other; 
 but the bossy, lobular forms of the tumors, together with the previous 
 history and other signs of syphilis, or, in the absence of both, the 
 notable cachexia of cancer, if present, enable us to be pretty confi- 
 dent as to our differential diagnosis. In reasonable doubt an accurate 
 blood count with differentiation of white cells will help us much. A 
 decided and relative increase of lymphocytes and of eosinophile cells, 
 according to Neusser or Cabot, would make this point very valuable. 
 Of course, " a disappearance of the tumor after a tentative antisyph- 
 ilitic treatment argues most positively in favor of gumma." 2 
 
 So far as clinical symptoms go, syphilitic cirrhosis resembles one of 
 the other forms. There may be jaundice and no ascites ; there may 
 be both ascites and jaundice. 3 On the other hand, there are instances 
 in which neither sign is present. At an advanced stage, however, 
 ascites can usually be determined ; and what is of particular value is 
 
 1 Ibid. cit. 2 Einhorn, Medical Record, August 17, 1901. 
 
 * Stockton states when jaundice occurs, even with apparent alcoholic cirrhosis, especially 
 if accompanied by cachexia, it is well to suspect syphilis. — Medical News, June 28, 1902, 
 p. 1244. 
 
CIRRHOSES OF THE LIVER. 157 
 
 the localized pain in the right hypochondrium which is usually present. 
 These pains are not constant, as a rule, but come on intermittently, or 
 at all events are greatly intensified if previously they have been present 
 in a mild, dull form. The pains during the exacerbations may become 
 so intense as almost to resemble those of gallstones. If the disease 
 has existed for a long while there is decided loss of weight, but scarcely 
 ever to the degree which characterizes malignant disease. Constipa- 
 tion and various functional disturbances of the stomach and intestines 
 are frequently present. 
 
 The congenital form of syphilis of the liver I do not remember to 
 have met with ; if I have my memory is too uncertain to be a faithful 
 reporter. 1 By those who have seen or described it it is said to be a 
 diffuse fibrosis, where the abnormal tissue formation penetrates into the 
 lobules or between the cells. The fibrous tissue is an immature devel- 
 opment. The liver itself is large and it is accompanied by jaundice, 
 ascites, and emaciation. 2 While as regards the pure pathology of 
 cirrhosis, as Cheadle says, there is more or less unanimity among 
 writers, this is not true of the causation of symptoms as connected with 
 morbid anatomy, nor of the course and clinical manifestations of the 
 disease in its various forms. One of the questions for settlement is to 
 know whether the atrophic form is anything more than a later stage of 
 the hypertrophic. Further, more definite judgment as to Hanot's 
 biliary cirrhosis is desired, and as to whether hypertrophic cirrhosis is 
 a real entity. These and many others are of singular interest. It is 
 ordinarily accepted that atrophic cirrhosis is mainly caused by alcohol ; 
 indeed, that it is the essential cause in the vast number of cases. Still, 
 malaria has seemed to be a sinning factor at times. Unfortunately, a 
 typical case of malarial origin is rarely found, at least with us in New 
 York. This may be accounted for, and doubtless is, by the relatively 
 mild form of malaria from which we suffer. The sestivo-autumnal 
 sort, with the characteristic crescents in the blood, does not occur 
 often. They are relatively exceptional. Now, it is in just these cases or 
 those of long-continued malarial cachexia, where we find great enlarge- 
 ment with fibroid induration of the spleen and also of other abdominal 
 organs, notably the kidneys. Why, then, should we anticipate finding 
 
 1 According to Osier it " is rare and nearly always overlooked." 
 
 2 Vide Cheadle. Lumleian Lectures for 1900. It affords me great pleasure in this connec- 
 tion to speak with admiration of these lectures, and to state that I have freely used them in 
 writing this paper. Indeed, I have followed his outlines (Cheadle's) because I could find 
 none better. 
 
 Since the above was written, Dr. George G. Sears and Dr. F. T. Lord have published in the 
 Boston Medical and Surgical Journal of September 11, 1902, a very important paper on cir- 
 rhosis of the liver, based on all the fatal cases in the Boston City Hospital and the Massa- 
 chusetts Hospital since 1896 in which the diagnosis was proved by histological examination. 
 Many of their conclusions, according to the London Lancet of October 15, 1902, are only con- 
 firmatory of those published in England by Dr. Cheadle and by Dr. Hale White. 
 
158 CTRRHOSES OF THE LIVER. 
 
 well-marked morbid effects of this sort in the liver if, as I do believe, 
 the liver as an organ is not nearly so apt to be much affected by 
 malarial poison as is the spleen ? Also, I would state that it is most 
 unusual for us to discover cases of profound malarial poisoning where 
 we could absolutely eliminate the disastrous influence of alcohol from 
 the equation ; and yet it is stated, even by those who claim never to 
 have seen a case of malarial cirrhosis, that there is nothing absolutely 
 improbable in the assumption, inasmuch as malarial indurated spleen 
 is fully determined. To my mind, this reasoning by analogy is very 
 lame and inapplicable to the liver, in view of the fact of. its very dif- 
 ferent structure and functions. When we consider how prone the liver 
 is to become engorged and somewhat cirrhotic in all cardiac affections 
 as well as in all obstructive lung diseases, it would seemingly be doubly 
 reasonable to eliminate the malarial factor in causation, unless pretty 
 clearly evident. I direct particular attention to this statement, because 
 I know that in most text-books malaria is insisted upon as a cause of 
 atrophic cirrhosis of the liver. Osier, 1 in this connection, writes : " In 
 our large experience with malaria during the past nine years not a 
 single case of advanced cirrhosis due to this cause has been seen in 
 the wards or autopsy-room of the Johns Hopkins Hospital." Now, it 
 is well known that the malarial manifestations found in the city of 
 Baltimore — a few indigenous, many coming from regions farther South 
 — are more virulent than those we meet with in New York or other 
 cities of the North in the United States. 
 
 Osier also writes, 2 in speaking of the liver : " Only those cases in 
 which the history of chronic malaria is definite, and in which the 
 melanosis of both liver and spleen coexist, should be regarded as of 
 paludal origin." 
 
 There seems to be little doubt, also, that hypertrophic and atrophic 
 alcoholic cirrhosis are distinct forms of disease and not different stages 
 of the same form. This affirmation seems reasonable when we consider 
 the very marked difference in the distribution of the fibrosis as well as 
 of its nature in the two cases. In the one the affection is markedly 
 multilobular ; in the other it is monolobular in quite as pronounced 
 degree. According to Cheadle, the error in confounding the two dis- 
 eases arose originally from the hypothesis that Hanot's so-called biliary 
 cirrhosis was simply the hypertrophic form. In many instances of cir- 
 rhosis of the latter form there is unquestionably a period when the liver is 
 simply congested and enlarged, and yet no formation of abnormal fibrous 
 tissue is yet begun, not to speak of any degree of contracture which 
 later on may prevail. In these cases the liver is said to be much softer 
 than it is where hypertrophic cirrhosis has become developed. This 
 
 1 Practice, fourth edition, p. 570. " Ibid, cit., p. 209. 
 
CIRRHOSES OF THE LIVER. 159 
 
 statement is no doubt true, and can be shown obviously in the autopsy- 
 room on rare occasions. When it comes to actual clinical work and 
 interpretation I am obliged to confess that this stated hardness as 
 compared with softness, where the large liver is merely congested, is 
 very difficult to differentiate. I have seen many cases of enlarged, 
 smooth liver where there were few or no symptoms of ill health, unless, 
 perhaps, slight evidences of dyspepsia should pass for such. In these 
 cases the tactile sensations, so far as relative hardness is concerned, 
 revealed little or nothing from this standpoint. This judgment is spe- 
 cially correct, I am confident, where the patient is corpulent, with thick 
 abdominal walls, due to the deposit of adipose tissue. In spare, meagre 
 individuals, with lack of muscular tone and relaxed abdominal walls, 
 the problem to be settled is much easier, and we may indeed say, truth- 
 fully, " Liver is hard or liver is soft." Of course, we should never 
 expect to find in hypertrophic cirrhosis the extreme hardness to tactile 
 sensations which is characteristic of the atrophic form ; nor is it 
 rational to expect it when we consider the very great difference which 
 exists in the variety of the fibrosis — fine in one case, coarse in the other. 
 The same cause — alcohol — which produces fibrosis of the liver also 
 effects interstitial changes in other abdominal organs, and particularly 
 the kidneys, which are thus affected in a large proportion of cases. 
 
 Despite the fact that it is affirmed that jaundice does not occur in 
 atrophic cirrhosis, this statement cannot on inquiry and research be 
 confirmed. On the contrary, it would seem as though we may and do 
 have jaundice in all forms of cirrhosis. What is true is that jaundice 
 occurs earlier in the hypertrophic form than it does in the atrophic, 
 and hence, of course, when it does show itself in the latter form it is 
 a sign of very bad augury. Many of the particular symptoms given 
 by Hanot to designate specially his form of biliary cirrhosis are to be 
 met with in the ordinary hypertrophic form, many of which are doubt- 
 less alcoholic ; but when we come to consider the whole description of 
 this writer we fail to find him in accord with other observers — mainly 
 outside of France. Even the hyperplasia of bile ducts which Hanot 
 considers so characteristic may be found in other forms. The jaundice 
 does not always occur in the usual hypertrophic form, nor, again, is 
 ascites always absent, and the spleen may not be visibly enlarged. 
 Pain and pyrexia simply show advent of perihepatitis, and, although 
 frequent in the hypertrophic form, it may also occur in other 
 forms. Nervous phenomena and the typhoid state are more frequent 
 in this form, but they are not absolutely distinctive. Chronicity is 
 not coastant, and, as we see, already, cases do not conform in all 
 respects to a purely classical type. Where alcohol is a prominent 
 factor in causation the symptoms approximate those of the atrophic 
 form. No doubt in just such instances the hypertrophic liver is spe- 
 
160 CIRRHOSES OF THE LIVER. 
 
 cially hard. The syphilitic liver, like the hypertrophic form, is often 
 enlarged, extending in the right mammary line far beyond the right free 
 margin of the ribs. If gummata are present they may be recognized, as 
 already stated, by the distinct irregularities or bossing of the surface. 
 If instead of gummata there is a cirrhotic process due to syphilis, the 
 liver may also present a swollen appearance, and this is also true if 
 amyloid degeneration has become manifest, which may be. shown in 
 advanced syphilitic conditions of the liver. In both syphilitic cirrhosis 
 and amyloid liver the organ is hard and relatively smooth (Einhorn), 
 and in the former case the fibrosis is said to be diffuse and monolobular. 
 (Cheadle.) Not always is the syphilitic liver large ; it may be small, 
 and is thus often confounded with the alcoholic liver. This is especially 
 to be regretted from a therapeutic standpoint, knowing as we do how 
 invaluable antisyphilitic treatment is in these cases. Perihepatitis, while 
 not pathognomonic of syphilitic liver, occurs very frequently in connec- 
 tion with it. Moreover, in this form a similar condition is more apt 
 to extend to other organs, particularly to the peritoneum, where it 
 causes that adhesive inflammation which of itself is quite characteristic. 
 Where syphilitic cirrhosis exists it may be more or less advanced. 
 Indeed, its presence may only be revealed by a slight scarring of the 
 free surface and some thickening of the hepatic capsule. Such patho- 
 logical conditions may serve to fix a diagnosis post-mortem where there 
 has been no syphilitic history and where signs and symptoms during life 
 left one in reasonable doubt as to the etiology of the case. Inasmuch 
 as syphilis of the liver is a late form of the disease, I have known 
 instances where the patient seemed almost oblivious of his ever having 
 had it, and where he could only with some difficulty be made to under- 
 stand any connection between his previous history and his actual symp- 
 tom?. I am now having in mind educated and fairly intelligent men 
 of the world. This is a practical observation of importance from the 
 point of view of insistence upon antisyphilitic treatment at times, even 
 though the patient is skeptical and disposed to resist or follow out his 
 own impressions of his ailment. No organ at times becomes more 
 important in the history of hepatic cirrhosis than the heart. As soon 
 as it shows symptoms even of dynamic inefficiency immediately there 
 is a tendency to venous stagnation, which must promote growth of 
 fibrous tissue and development of ascites. Alcohol, as we know, affects 
 the heart as- it does other organs ; but here it seems rather, as a rule, 
 to produce fatty or other degeneration of the muscular fibres than 
 deposits in interstitial tissues. No doubt these cardiac changes account 
 for many sudden deaths in syncope, or sudden asthenia otherwise unex- 
 plained. Frequent stimulation may tide over some of these attacks, 
 but to be effective it must be employed without delay. 
 
 I have already indicated the effect of alcohol upon many abdominal 
 
CIRRH08E8 OF THE LIVER. 161 
 
 organs. Of course, we can understand if these organs are much impli- 
 • cated their influence upon the rapid march of hepatic cirrhosis is greatly 
 felt. Hepatic cirrhosis is particularly liable to be complicated with 
 acute miliary tuberculosis of some organs, and very many patients die 
 from this rather than the hepatic disease itself. In this way it is shown 
 how imperative it is for these patients to keep up good nutrition and 
 live all the while nearly in the open air. The statements of many 
 observers corroborate this. Thus Osier writes : "In seven of my 
 series the patients died with either acute tuberculous peritonitis or 
 acute tuberculous pleurisy." 1 It is curious, on the other hand, that 
 distinguished and careful clinicians like Flint and Fagge apparently 
 make no note of it. 
 
 The prognosis of hepatic cirrhosis has usually been most gloomy. 
 Once ascites is revealed the patient's lease of life appears very 
 limited. To-day we are more encouraged and regard certain cases 
 very hopefully. Even in the advanced cases of atrophic cirrhosis we 
 cannot always be sure to what extent some, not to say many, of the 
 liver cells retain good functional power — at all events, power sufficient 
 to help continue good nutrition if attending conditions be treated 
 rationally. 
 
 It is recognized generally that we have no remedy which will make 
 disappear the formation of fibrous tissue in the liver ; but the ascites 
 may ba removed, even in these extreme cases, and allow the collateral 
 circulation to act, with relief, to a certain degree, of the obstructed 
 portal circulation. Then, every time effusion becomes considerable and 
 organs are interfered with in their action through pressure, let para- 
 centesis be repeated. 
 
 It has been shown by Fagge that cirrhosis often becomes quiescent 
 before it reaches its final stage. 2 Flint seems to corroborate this view, 
 because he says emphatically that life has lasted months and years after 
 ascites had become developed and been recognized. Even in some 
 atrophic cases of advanced type nutrition is still preserved, and this is 
 always of good augury, because, despite the ascites, it shows some liver 
 cells able to function normally. Of course, there is a possibility in 
 these cases that we have not to do with a true cirrhosis of the liver 
 itself, but with a perihepatitis or chronic peritonitis which was very 
 probably the cause of the abdominal effusion. In this connection I 
 would quote Fagge 3 again to corroborate my statement. 
 
 In hypertrophic and syphilitic cirrhosis the prognosis is much more 
 hopeful. In the former case the development of fibrous tissue is of 
 immature form, and occurs more rapidly with intercurrent conspicuous 
 
 i Ibid, cit., p. 571. 
 
 8 Paper read before British Medical Association, 1883, vol. ii. p. 566. 
 
 3 Practice of Medicine, vol. ii. p. 315. 
 
162 CIRRHOSES OF THE LIVER. 
 
 cell proliferation. This rapidly formed connective tissue is never so 
 dense nor is it so destructive to the liver cells as that of the atrophic 
 form of cirrhosis. In these cases there is often relative youth and good 
 nutrition. Hence, from all these standpoints the prognosis is more 
 favorable. 
 
 The prognosis of hepatic syphilis is even more hopeful. Of ten cases 
 reported by Einhorn " only one patient died, and even this one had 
 been considerably benefited for five or six months, whereas all the 
 others were either perfectly cured or much improved." 1 
 
 Of course, if cirrhosis could be recognized at an early stage, and 
 before the advent of ascites, the outlook would not be immediately 
 unfavorable. Sometimes we are able to make this diagnosis from 
 certain prominent signs or symptoms : the indurated, large liver — an 
 organ enlarged — and also irregular, vascular stigmata on the skin and 
 face, and passing jaundice ; an enlarged heart, constipation, dyspeptic 
 symptoms, palpitations, and, it may be, some emaciation. We should 
 act in accordance with the manifest indications, and among these is 
 one primary and essential to correct absolutely — an alcoholic habit, if, 
 as is usual, it has previously existed. 
 
 We often meet with combined cases of alcoholic and syphilitic cir- 
 rhosis. Some such cases have been known to recover during several 
 years. This recovery was evident through subsidence of the ascites 
 and recovery of the general health. (Cheadle.) 
 
 The first and most important indication of useful treatment arises 
 from the point of view of arresting growth of fibrous tissue in the liver, 
 and in this way the preservation of the remaining healthy liver cells. 
 This is accomplished, if at all, by abandonment of the use of alcohol, 
 which cannot be too urgently insisted upon in the great majority of in- 
 stances. Of course, there may arise states of anaemia, prostration, or 
 great weakness in which a moderate amount of good alcoholic stimu- 
 lant may be imperatively required, at least for a time, and under such 
 circumstances should surely not be withheld. This must be regarded 
 merely as a temporary necessity, and we must have in view constantly 
 the fact that it has been shown that even if fatty degeneration of liver 
 cells be begun it will often be arrested if alcohol be wholly given up. 
 A judiciously arranged dietary is only of secondary importance, and 
 yet it is undoubtedly true that the digestive organs must be supplied 
 with suitable food products, properly prepared, to sustain active nutri- 
 tion and to ward off, as far as may be, certain functional or even 
 organic disturbances in part dependent upon auto-intoxication of 
 gastro-intestinal origin. Fats and sugars should be notably diminished 
 in the dietary, for the reason that in the impaired liver functional power 
 
 i Ibid. cit. 
 
CIRRHOSE8 OF THE LIVER. 163 
 
 is decreased, and is shown especially in its inability for proper assimi- 
 lation of foods containing many such elements. The simplest dietary 
 of milk, eggs, stewed fruits, well-cooked fresh vegetables, and the 
 lighter meats is of decided utility. Semmola's is the only rational 
 treatment, viz., to reduce the quantity of food to a minimum and give 
 it in a form which will tax the liver cells least. Milk is undeniably 
 the best of all ; but when this becomes intolerable, as it often does, 
 eggs and other light food may be added. No doubt some instances of 
 cirrhosis of the liver originate in auto-inloxication from the stomach 
 and bowels. In all instances aggravation of the developed disease may 
 result from it ; hence over and beyond appropriate dietary the use of 
 suitable antiseptic remedies like guaiaquin and benzosol (Gasper) may 
 be formally indicated. Among drugs which have a decided action, 
 aad one most beneficial in almost all syphilitic cases, iodide of potas 
 sium easily ranks first. There can be no question, in view of very 
 many recorded cases, that guramata in their early stages are reabsorbed 
 through its action. It is highly probable, also, that perihepatitis and 
 similar conditions of other abdominal organs (spleen, peritoneum) are 
 very favorably affected. It is not a sufficient reason to proscribe the use 
 of the iodide because the syphilitic nature of the case is not always per- 
 fectly clear. In many instances doubt may legitimately exist. Indeed, 
 in many combined alcoholic and syphilitic cases a positive differential 
 diagnosis as to how much is due to alcohol, how much caused by 
 syphilis, is impossible. The only safe rule, then, is to give up alcohol 
 and take the iodide. Again, in instances where there is no history of 
 syphilis and no evidence discoverable of its presence, it is yet wise at 
 times to administer the iodide, the reason being that purely alcoholic 1 
 cases and those due to syphilis of the nature of an interstitial hepatitis 
 are often confounded one with the other. 
 
 In the event of evidences of heart weakness, and in view of the 
 well-known post-mortem findings, digitalis and heart tonics should be 
 employed judiciously. Salines and diuretics are of some use in the 
 relief of ascites, but, as a rule, are of more value in warding off its 
 return for a while after paracentesis than in preventing the necessity of 
 this operation. The explanation of this is not perfectly clear, although 
 a theory for it may be readily offered, viz., that the absorbents re- 
 lieved from pressure are more efficient. 2 Very active purgation by 
 the use of hydragogue cathartics is at no time indicated, as it is useless 
 and may become directly injurious by depleting the patient's strength 
 very much or by bringing on diarrhoea often difficult to arrest. On 
 
 1 Of the frequency of this form, one may judge from Flexner's report of autopsies done at 
 the Philadelphia Hospital. Among eighty-eight cases of syphilis of the liver, forty had inter- 
 stitial hepatitis.— Medical Record, October 19, 1901. 
 
 2 Thromboses of the portal vein may cause rapid re-accumulation of ascites. 
 
164 CIRRHOSES OF THE LIVER. 
 
 the other hand, the moderate use of mineral waters to keep the bowels 
 regular may be very necessary to the patient's welfare. 
 
 In the treatment of hypertrophic cirrhosis Nothnagel has wisely 
 insisted upon small, repeated doses of calomel. Vaughan believes that 
 later this form of disease will be treated mainly by surgery, as it is the 
 only way by which the gall-bladder and biliary vessels can be disin- 
 fected. 
 
 Billings quotes Kussmaul as using chloride of ammonium to prevent 
 proliferation of the connective tissue cells, and he (B.) claims in this 
 way he has seen induration of the liver disappear as well as some local 
 symptoms connected with the disease. 
 
 Whatever may have been the objections in former years to paracen- 
 tesis, legitimate or unsupported, to-day it seems very clear that in early 
 and repeated paracentesis the best hope of the patient lies. Even in 
 advanced instances of atrophic cirrhosis life is prolonged and suffering 
 diminished ; but in instances where we have an enlarged liver with 
 ascites, which in such cases often occurs when the disease is not far 
 advanced, we get our best results from paracentesis. The fluid may 
 recur in smaller quantity after each paracentesis, and in some 
 undoubted examples, after several operations, no fluid has recurred, 
 and so far as symptoms are concerned, we may properly say a recov- 
 ery has taken place. This may last for many years. I have had 
 at least one such instance in my practice. The patient recovered 
 from the ascites, and subsequently died of another disease than hepatic 
 cirrhosis, as was evident at the autopsy. The danger to-day of peri- 
 tonitis arising from paracentesis is very slight, indeed, if ordinary 
 aseptic precautions be observed. I do believe it is wiser to employ the 
 ordinary aspirator or Flint's modification of the Davidson syringe, 
 than the trocar and canula, and mainly because the flow of fluid is 
 easily regulated, and thus there is less danger of syncope or heart 
 failure, which might be directly caused by too rapid evacuation of fluid 
 where cardiac degeneration is present. This accident may also be 
 obviated, as we know, by the prompt use of a binder as the fluid flows 
 from the abdomen. The binder also is useful in delaying return of 
 ascites. There is less risk of serious injury to the intestines with the 
 small needle attached to the aspirator than with a moderate-sized trocar. 1 
 
 Unfortunately, paracentesis is not always thoroughly satisfactory. 
 The canula may become blocked in different ways and for different 
 reasons, not always easy to obviate. In our very desire to benefit our 
 patient and withdraw most of the fluid from the cavity we may run 
 the risk of wounding the intestine. Sometimes the cause of the obstruc- 
 tion of the canula is a piece of false membrane ; again it seems to be the 
 
 i British Medical Journal, 1883. 
 
CIRRH08ES OF THE LIVER. 165 
 
 intestinal wall, and we must be careful not to injure it. In some in- 
 stances where we expect to obtain a large quantity of fluid we really 
 get very little, which is discouragiug both to patient and physician. 
 Occasionally it seems as though the posture of the patient was respon- 
 sible for this, but I have found the difficulty to arise when the patient 
 was sitting up and also when the patient was lying down. 
 
 Some authors have objected to paracentesis because, they say, after 
 it the ascites recurs more rapidly, and that, besides the risks alluded 
 to, it is very depressing through loss of albumin from the blood on 
 every occasion it is performed. This objection has little or no value, 
 as a rule, especially if the patient be in fairly good general condition. 
 Of course, if the patient is very old and feeble, or the disease very 
 advanced, paracentesis is likely to hasten the fatal termination. On 
 the other hand, where the abdominal and thoracic organs have been 
 compressed or pushed away from their normal position by excess of 
 abdominal fluid there is no question that the fluid should be speedily 
 removed. Thus great distress is often relieved, the kidneys begin to 
 function with renewed activity, and the general condition of the patient 
 is notably improved. The lungs are enabled to breathe freely again, 
 and the heart becomes regular and fails to intermit. While getting 
 additional power very rapidly, cough, expectoration, hypostasis, and 
 even pleuritic effusion due to upward pressure soon disappear. Some- 
 times after paracentesis there is more or less leakage from the abdomen 
 through the hole made with the needle or trocar. This is often very 
 annoying to the patient, as his clothes and bedding become thoroughly 
 wet ; and yet it may be useful in a few instances from the fact that 
 the drainage continues for several hours after the operation is 
 concluded, and from regions the needle could not reach. In this 
 connection it is proper to refer to continuous abdominal drainage 
 by means of a permanent canula left in the abdomen after the trocar 
 is withdrawn. I performed this operation on one occasion, with 
 apparently some good result ; but the dangers from aspiration of air 
 into the cavity, peritonitis, and suppuration are such that I felt later 
 that better ultimate results could be expected from repeated puncture 
 and before the fluid was permitted to reaccumulate in too large quan- 
 tity, or caused any notable distress, or interfered much with the healthy 
 function of any important organ. 
 
 -" The removal of fluid by continuous drainage has been practised 
 with some success by Dr. Caille and Dr. Elliot in America, and by Dr. 
 Urso in Italy." 1 And certainly in some cases it would appear to be 
 safer and quite as effective as the radical operation to produce new 
 anastomoses. 
 
 On the other hand, Weir, 2 who used permanent drainage in connec- 
 
 1 Cheadle, p. 88. 2 The American Journal of the Medical Sciences, 1899, p. 723. 
 
166 CIRRHOSES OF THE LIVER. 
 
 tion with or rather subsequent to the radical operation, " would here- 
 after prefer to resort to paracentesis if it became necessary, as the risk 
 seems less." 
 
 It is surprising at times to remark the powerful diuretic effect of 
 paracentesis. Kidneys that previous to it were inactive become active, 
 urine that was albuminous, of high specific gravity, and contained casts 
 accompanied by urcemic symptoms, has changed remarkably. The 
 flow of urine has wonderfully increased in quantity, and its characters 
 have become almost normal, while all ursemic evidences have soon disap- 
 peared. Without the paracentesis both purgatives and diuretics seemed 
 wholly worthless to produce these much-desired effects. 
 
 If we wish to get the best effects from repeated tapping we must have 
 patients under our immediate care, so that they may be tapped again 
 when the proper moment arrives. Tapping should be repeated in 
 proper cases until fluid ceases to reaccumulate. During this period 
 it should be our effort to maintain the patient's nutrition to the highest 
 degree possible. Through constant care and attention we obtain the 
 best results ; through carelessness or permitting the patient to absent 
 himself too long from observation we have often cause for regret, and 
 the patient relapses into an impoverished and threatening state. 
 
 On the other hand, Hale White's observations would go to show 
 " that in the cases of cirrhosis of the liver with chronic peritonitis the 
 survival for a considerable length of time was due to the fact that the 
 latter lesion assists in some way in the formation of a collateral circu- 
 lation." 1 
 
 Now, as Osier writes : " We know that extreme grades of contraction 
 of the liver may persist for years without symptoms when the com- 
 pensatory circulation exists. The so-called cure of cirrhosis means the 
 re- establishment of this compensation." 2 
 
 Upon this idea of re-establishment of this compensation rests the 
 modern radical surgical treatment of cirrhosis of the liver. The method 
 is to promote adhesions between the liver, spleen, and abdominal walls 
 and diaphragm, thus helping collateral circulation by new vascular 
 channels. This is attempted, first, by completely evacuating the 
 abdominal contents, and then, by thorough scrubbing of the organs 
 referred to, set up a certain amount of irritation which shall tend to 
 make the formation of new vessels more probable. In this connection 
 Cheadle is of the opinion that if we consider the conditions where the 
 new vessels are found naturally they do not seem favorable, being, 
 associated with the worst cases, and do not lead one to try to produce 
 them artificially. Opposed to this view we would cite three cases- 
 
 i The American Journal of the Medical Sciences, March, 1901, p. 259. 
 2 Ibid, cit., p. 566. 
 
CIRRHOSES OF THE LIVER. 167 
 
 cured : one of Osier's, 1 operated on by Dr. Bloodgood at Johns Hopkins 
 Hospital ; another of Brown's, 2 another of Frazier's. 3 In one instance 
 under my care, operated on by Dr. F. H. Markoe, nearly two years 
 ago, the patient has had recurrent ascites, necessitating repeated tap- 
 pings since the radical operation. Two of Osier's cases were unsuc- 
 cessful. As regards one or two tappings after the operation, this we 
 should expect where a drainage-tube has not been introduced, the 
 reason being that time is required for the formation of adhesions and 
 new veins ; and the introduction of the drainage-tube is now shown to 
 be bad from a surgical standpoint, as it opens a channel of infection. 
 (Frazier.) 
 
 In Dr. Brown's successful case, at first referred to in the Presbyterian 
 Hospital Reports for 1900, and the patient subsequently presented at a 
 meeting of the New York State Medical Society, held October 16, 1901, 
 at the New York Academy of Medicine, the condition was one of 
 atrophic cirrhosis, due to alcohol. There was no syphilis and no malaria, 
 although the spleen was enlarged. There was no pronounced venous 
 engorgement on the abdominal walls. The patient was operated upon 
 over two years ago. There has been no recurrence of ascites, and the 
 nutrition remains good. The patient is doing his usual work — that 
 of a day laborer. 
 
 Frazier 4 in the remarks he makes, prompted no doubt by a success- 
 ful case, wisely insists, as a formal contraindication to the operation, 
 upon the absolute lack of functional power in the liver cells — i. e. y 
 shown usually by extreme atrophy. (Packard.) In his judgment, the 
 presence of cardiac and renal degeneration is only a relative contra- 
 indication. He also states that it is essential, in order to avoid fatal 
 toxaemia, that the collateral circulation should be formed gradually. 
 Where the cases have been carefully selected he " believes the opera- 
 tion has a future." 
 
 Fourteen cases are thus far reported, seven of which appear to have 
 been materially benefited or cured by the operation (Brown) and three 
 died from the operation. 5 " The many instances of practical cure fol- 
 lowing tapping, and the uncertainty of the exact pathological state of 
 the liver, together with the somewhat formidable character of the opera- 
 tion and liability of infection, invest the operation at present with a. 
 large element of doubtful expediency." 6 These remarks, cited textu- 
 ally from Dr. J. D. Bryant's work on Operative Surgery, appear to me 
 eminently wise. 
 
 1 Ibid, cit., p. 577. - New York Medical Eecord, October 19, 1901, p. 637. 
 
 3 The American Journal of the Medical Sciences, December, 1900, p. 661. 4 Loc. cit. 
 
 6 Later Packard reports twenty-two cases, with nine recoveries and eight deaths (The 
 American Journal of the Medical Sciences, March, 1901, p. 265), and in a "note" one 
 death— one doubtful. 
 
 6 Bryant, Operative Surgery, 1901, vol. ii. pp. 802, 803. 
 
168 CTBEHOSES OF THE LIVEE. 
 
 la all these cases, moreover, it is judicious to properly estimate the 
 amount of functional disturbance, if possible, of the liver cells (icterus, 
 acholic stools, urobilinuria, etc.) as well as the physical changes of the 
 liver itself. In it may be found, as Brown says, a formal contraindi- 
 cation to the wisdom of the operation. Neumann 1 also wisely insists 
 " that the liver cells be not too greatly impaired in their functional 
 capacities, and that every precaution should be taken in selecting 
 proper cases, in order not to permit discredit to fall upon so valuable 
 an operation." 
 
 Brown " feels assured that the great risks attending operations on 
 advanced and failing cases will be notably wanting in similar pro- 
 cedures applied in earlier stages of the disease." 2 No doubt this state- 
 ment is correct, but in my judgment it is correct only so far as it 
 applies to all important or dangerous surgical procedures. The great 
 difficulty is to convince the pure physician with the facts as reported 
 up to date, and allowing for errors of diagnosis with respect of the pre- 
 cise nature of the liver condition and for the concomitant conditions 
 almost always present (heart, kidneys, spleen, pancreas, etc.) that such 
 a stand is justified. I am scarcely of that opinion until it be shown 
 that the radical operation in similar instances gives better results than 
 the far less serious procedure of simple and repeated paracentesis. 
 
 Dr. Weir's standpoint appears to be a more rational one, viz., " The 
 operation was worthy of trial in apparently hopeless cases of liver 
 cirrhosis in which the abdomen rapidly refilled after repeated tapping, 
 and in which the large quantity of the fluid was producing fatal 
 exhaustion." 3 
 
 Dr. McBurney in discussing Dr. Weir's paper thought that analogy 
 with what occurred after simple incision in cases of tuberculous peri- 
 tonitis allowed one to question whether the relief of ascites in cirrhosis 
 of the liver which followed the radical operation was brought about 
 by the development and growth of vascular anastomoses. This view 
 of McBurney's seems to approximate that of Dr. Osborne, of New 
 Haven, and of Dr. Cheadle, already cited. 
 
 On the other hand, Packard and Le Conte 4 claim that " one of the 
 ways by which repeated tappings may aid in the recovery of cases of 
 cirrhosis of the liver is through the formation of adhesions similar to 
 those aimed at in the operative procedure, but to a less degree." Be 
 these views as they may, I cordially assent to their previous state- 
 ment, 5 that " these cases of advanced cirrhosis of the liver, operated 
 on or not, die with evidence of progressive toxaemia and gradual failure 
 of all the organs to do their proper work." 
 
 i Quoted by Brown (p. 11). 2 Page 16. 
 
 3 New York Medical Record, January 28, 1899, p. 143. 
 
 4 The American Journal of the Medical Sciences, March, 1901. 6 Ibid., p. 257. 
 
CIRRHOSES OF THE LIVER. 169 
 
 Despite these views, they state in their conclusions, as their opinion, 
 " that where the diagnosis of pure portal cirrhosis of the liver can be 
 made, and where persistent and well-directed medical treatment is 
 productive of insignificant results, the operation should be strongly 
 recommended." 
 
 Here, it seems to me, the great difficulty lies in this precise diagnosis 
 at the present time ; for do we not know that constantly our autopsies 
 show that concomitant lesions exist which render nugatory all radical 
 op3ration3 — i. e., other kinds of cirrhosis, chronic peritonitis, advanced 
 degeneration of other organs, like the heart and kidneys, etc. ? 
 
 There can be little doubt that in very many cases of hepatic cir- 
 rhosis it is important to do what we can medicinally and otherwise to 
 keep the heart in a vigorous state. Once it becomes inefficient func- 
 tioually, either because of simple dynamic weakness or owing to struc- 
 tural changes, the development of the ascites is certainly more rapid 
 and more apt to recur. We recognize in this way that the obstructed 
 portal circulation due to fibrosis is also heightened notably by venous 
 stagnation caused directly by impaired heart power. ' No doubt the 
 explanation of instances of early effusion in hypertrophic cirrhosis is 
 thus often satisfactorily given. If such a view be admitted it can be 
 readily understood why we can obtain good effects from suitable treat- 
 ment in just such cases. An important part of this treatment must be 
 the maintenance of sufficient cardiac power if it be possible to prevent 
 venous stagnation in the liver. 
 
 In instances where venous stagnation occurs of cardiac origin the hepa- 
 tic veins at the centre of the lobules are especially affected, and it is also 
 true in these instances that here is likely to be formed the fine fibrous 
 deposit which, as we have seen, characterizes hypertrophic cirrhosis. 
 Not always is the cardiac inefficiency shown by evident physical signs, 
 nor, indeed, by the presence of ascites ; still, in hypertrophic cirrhosis 
 or simple engorged liver it is a safe plan to give, for a while at least, 
 small, repeated doses of digitalis, and note its obvious effects either on 
 the size of the liver directly or some of the suggestive symptoms con- 
 nected therewith. 
 
 Appended are histories of cases of " omental anastomosis." 
 
 Case I. — Case of cirrhosis of the liver in which radical operation 
 was performed by Dr. F. H. Markoe. J. S., aged fifty years, married ; 
 hotel steward ; born in the United States ; admitted to St. Luke's 
 Hospital June 30, 1898. Alcoholic history ; suffering from ascites. 
 Liver probably enlarged ; rough and nodular. Abdomen much dis- 
 tended ; evidences of fluid ; superficial veins enlarged. 
 
 First Aspiration. Three days after admission, 125 ounces obtained ; 
 second : eleven days later 128 ounces obtained. 
 
 Treatment nil. Left hospital July 22, 1898 ; re-entered, December 
 6, 1898. 
 
 12 
 
170 CIRRHOSES OF THE LIVER. 
 
 Abdominal fluid increased in quantity as compared with quantity 
 before the last tapping, July, 1898. 
 
 Third Aspiration. Two days after admission, 370 ounces obtained ; 
 fourth : five weeks after admission, 400 ounces obtained ; fifth : seven 
 and a half weeks after admission 440 ounces obtained ; sixth : ten and 
 a half weeks after admission, 475 ounces obtained. 
 
 Treatment. Digitalis, iodide of potash, theobromine, copaiba, etc. 
 Left hospital March 1, 1899, and readmitted two weeks later; abdo- 
 men greatly distended. 
 
 Seventh Aspiration. Day after admission ; 390 ounces obtained. 
 Left hospital, and readmitted April 17, 1899. 
 
 Eighth Aspiration. Day admitted ; 426 ounces obtained. 
 
 May 13th. Ninth : 390 ounces obtained. 
 
 Jane 14:th. Tenth : 450 ounces obtained. 
 
 July 10th. Eleventh : 330 ounces obtained. 
 
 August 12th. Twelfth : 452 ounces obtained. 
 
 October 1th. Thirteenth : 520 ounces obtained. 
 
 November lMh. Fourteenth : 510 ounces obtained. 
 
 Treatment. Codeine for cough. 
 
 January 22, 1900, Dr. F. H. Markoe performed upon the patient the 
 operation of " omental anastomosis," and 500 ounces of light yellowish 
 fluid slowly evacuated from the abdomen. On palpation, the liver 
 was found large ; also some abdominal adhesions. Vomiting of green 
 fluid off and on for six days following operation. 
 
 Fourteenth Aspiration. Six weeks after operation ; 138 ounces ob- 
 tained. 
 
 Subsequently, up to November, 1901 (twenty-two months later), 
 patient has been aspirated about fifteen to seventeen times, which, with 
 those performed before operation, make about thirty in all. 
 
 November, 1901. He is now confined to bed, and is unable to leave 
 it by reason of asthenia. 1 
 
 Case II. — A second case of " omental anastomosis " for cirrhosis of 
 the liver was performed by Dr. F. H. Markoe at St. Luke's Hospital, 
 April 27, 1901. The patient had marked ascites ; was a boy, aged thir- 
 teen years, and had been quite a drinker. Subsequent to the operation 
 the patient was tapped once before he left the hospital, on May 21, 
 1901. Since that date he has returned about every six weeks to have 
 the fluid removed from the abdominal cavity. The patient's general 
 condition is about the same as before the operation. The ascites is 
 probably somewhat less. 
 
 Case III.— The following case of " omental anastomosis " is one in 
 which Dr. F. W. Murray operated. 
 
 History. P. A. B., married, aged forty-eight years; no specific dis- 
 ease ; excessive alcoholic habits. 
 
 Four months before admission to St. Luke's Hospital patient noticed 
 yellow conjunctivae and loss of flesh and strength. His abdomen 
 increased by eight inches in size. This increase subsided for a time 
 under calomel and salines, but soon returned. April 2, 1900, entered 
 hospital ; 328 ounces of fluid removed by tapping ; largely reaccumu- 
 lated in two or three days. Transferred to surgical service April 18th. 
 
 Abdomen measured 44£ inches at a point three and a half inches 
 
 1 Patient died December 15, 1901, from heart failure. 
 
CIRRHOSE8 OF THE LIVER. 171 
 
 above the umbilicus ; percussion flat over the whole abdomen. Opera- 
 tion April 19th, by Dr. Murray. Incision four inches long at the 
 left of the umbilicus ; 3} gallons of fluid removed ; omentum thick- 
 ened and vessels injected ; sutured to parietal peritoneum by five inter- 
 rupted sutures of No. 1 catgut ; stood operation well. Urine acid ; 
 specific gravity, 1020; slight trace of albumin; no sugar; few hyaline 
 casts. 
 
 Aspirated April 23, and 64 ounces of fluid obtained. April 30th, 
 circumference 39 inches. May 2d, primary union of wounds. May 
 12th, oedema of feet ; stuporous ; pulse rapid ; coryza marked ; 
 erythema over nose, diagnosed as erysipelas. May 13th, temperature 
 between 98.3° and 99° F. Pulse varies from 90 to 100. Respiration, 
 24. Died. (Above history furnished by Dr. Martin.) 
 
 Note. — Since writing the foregoing paper a valuable contribution 
 from the pen of Dr. George E. Brewer, on " The Surgical Treatment 
 of Ascites Due to Cirrhosis of the Liver," has been published. From 
 it we take the report of " 5 personal cases and analyses in tabular form 
 from about 50 more from the literature." From reviewing these statis- 
 tics Brewer finds at least 6 patients who have been cured of ascites by 
 this procedure — i e., Talma-Morrison operation — and who have re- 
 mained well for two years or more ; 6 others have died, with relief of 
 this symptom from two to six months before death, or who had not 
 been under observation long enough to demonstrate a permanent cure. 
 Another patient suffering from hemorrhage of the alimentary canal 
 was promptly cured by this operation. Many others have been mate- 
 rially benefited ; 38 have recovered from the operation ; and, consid- 
 ering that the great majority of these were within a few weeks of 
 inevitable death, he thinks that it should encourage us to suggest 
 operation at an earlier and more favorable stage of the disease. If 
 this suggestion is followed he believes that statistics will show a great 
 improvement over those he is able at this time to present. 1 
 
 In a later contribution on this subject Dr. W. Murrell, of Westmin- 
 ster, writes 2 that " much depends on careful selection, and the best 
 results would probably be obtained in the pre-ascitic stage when the 
 diagnosis rests on the alcoholic history, with haematemesis and enlarge- 
 ment of the liver and spleen." 
 
 1 Journal of the American Medical Association, February 22, 1902, p. 135. 
 
 2 Lancet, June 7, 1902, p. 1604. 
 

 C'OVj. I. 
 
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