Some Remarks on Pneumonia 
and the Cause of Heart 
Failure, with Report 
of a Case. 
BY 
L. HARDISON METTLER, A. M., M. D., 
CHICAGO. 
REPRINTED PROM THE 
Xrtu Forft f&eliical Journal 
for July 30, 1892. Reprinted from the Next) York Medical Journal 
for July 30, 1892. 
SOME REMARKS ON PNEUMONIA 
AND THE CAUSE OF HEART FAILURE, 
WITH REPORT OF A CASE. 
By L. HARRISON METTLER, A. M., M. D., 
CIIICAGO. 
At present there are two views in regard to the cause 
of the much-dreaded heart failure of pneumonia. In a 
loose way they may he characterized as the mechanical and 
chemical theories. The mechanical theory is the older of 
the two, and attributes the cardiac weakness occurring 
about the crisis of the disease to the changes produced in 
the heart muscle by the prolonged high temperature and to 
the difficulty which the heart experiences in forcing the 
blood through the obstructed lungs. The chemical theory 
assigns the heart failure to a nervous source. It insists 
that the nervous apparatus of the circulatory system is 
poisoned by certain toxic matters, ptomaines and other 
substances, retained in the blood. It fails to explain just 
what the nature of the poison is, how it is generated, and in 
what particular manner it affects the vaso-motor nervous 
apparatus. ' Many writers approve of both the mechanical 
and chemical theories, and accord an equal importance to 
both as the causative agents in pneumonic heart failure. 
Copyright, 1892, by D. Appleton and Company. 2 
80ME REMARKS OX PNEUMONIA 
In tbe absence of more positive knowledge, this may be a 
discreet position to assume, but in the majority of cases it 
seems to me that tbe chemical theory offers tbe more satis- 
factory explanation. My attention was forcibly turned to 
this subject by tbe following case, which is not reported, 
however, as an unusual one by any means: 
H. J. B., a young man, twenty-two years of age, with a 
fairly good family history, was one day overcome during busi- 
ness hours with a sudden attack of vertigo and general prostra- 
tion. He did not lose consciousness, but at once went home, 
took to his bed, and attempted to treat himself with some 
simple home remedies. When I first saw him, September 15, 
1891, I learned the following facts: He had been considerably 
annoyed with nasa. catarrh, and for the last few weeks had 
been indulging in frequent cold baths. He described a kind of 
“queer feeling” over his whole body, and complained of a se- 
vere aching in tbe neighborhood of bis joints. Near the base 
of the left lung he felt a short, sharp pain whenever he took a 
long breath. His bowels had been averaging about two move- 
ments in the twenty-four hours. His tongue was thickly 
coated, red along the edges, and deeply cracked down the mid- 
dle. He was made uncomfortable by a constant bad taste. 
Tea and coffee he indulged in freely, but no alcoholics; smoked 
on an average two cigars a day ; and as a general thing enjoyed 
a good appetite. He was afraid that his heart was diseased; 
and between the difficult, shallow breathing and the dread of 
impending dissolution, it was apparent that he was in great dis- 
tress. His face was hot and flushed. The pulse was 96, the 
temperature 103°. He complained especially of an intense 
throbbing headache in the frontal region. There was no epis- 
taxis or other indications of typhoid poisoning. Examination 
of the chest revealed a slight dullness near the base of both 
lungs, more marked, however, on the left side. There were no 
rales or perceptible fremitus. In fact, the physical signs at 
this time were so insignificant as to be almost nil. I gave at 
once a tablet containing a quarter of a grain of sulphate of mor- 
phine, one one hundred and twentieth of a grain of sulphate of AND THE CAUSE OF HEART FAILURE. 
3 
atropine, and two drops of the tinctur of aconite root. He 
was then ordered to take at once eight grains of the sulphate of 
quinine, continuing afterward with two grains every two 
hours. A mustard poultice was to he applied to the chest, an 
abundant milk diet allowed, and a strong mustard foot-bath 
taken at bed-time. 
September 16th.—The patient slept during the night, but 
was extremely restless in his sleep. The mustard was removed 
from the chest before the skin had become reddened, otherwise 
the directions were carried out explicitly. The morning pulse 
and temperature were 96 and 102°. The tongue was redder 
and more deeply serrated. Absolute rest in bed was enjoined, 
and the mustard reapplied to the chest. He was ordered to take 
two drops of tincture of aconite root with three drops of tinct- 
ure of opium in water every hour, two grains of sulphate of qui- 
nine every two hours, milk punch, lemonade, and cracked ice ad 
libitum. In my afternoon visit I found the patient feeling 
somewhat easier, but still restless and complaining of the pain 
near the base of the left lung. The pulse registered 100, the 
temperature 102°. I then dry-cupped him very freely, both ante- 
riorly and posteriorly, over the lungs, which he declared gave 
him almost instant relief. Eight grains of the sulphate of 
quinine were prescribed at once, and ten grains more ordered 
to be taken an hour later. The mustard was soon again ap- 
plied to the chest, and after its removal the upper part of the 
patient’s body was wrapped in a thick wadding of raw cotton 
covered with oiled silk. At bed-time he was ordered to begin 
taking the aconite and opium drops every three hours for the 
rest of the night, and occasionally a teaspoonful of whisky in 
sweetened water. 
17ih.—The night had been close and the patient suffered a 
good deal from restlessness, lie had been able to take very 
little nourishment and almost no whisky, because the stomach 
refused to retain either. The bowels moved about six times, 
with loose but not particularly offensive stools. The intolerable 
pain about the lungs had completely disappeared, but there 
still remained considerable headache. The pulse was 86, the 
temperature 102°. I ordered ten grains of sulphate of quinine 4 
SOME REMARKS ON PNEUMONIA 
at once, to be followed by two grains every two hours in con- 
junction with the aconite and opinm drops. The chest was 
kept enveloped in cotton. A teaspoonful of brandy was ad- 
ministered every three hours, and such nourishment as milk, 
beef tea, broths, and plain jellies given every two hours. In 
the afternoon the pulse numbered 84 and the temperature 
registered 100'8°. The patient said the brandy “ braced him 
up,” and in every way he seemed much better. The two-grain 
quinine pills, with the aconite and opium drops, were continued 
every four hours, while some nourishment, with a teaspoonful 
of the brandy, was given every two hours. 
18th.—Somewhat restless during the night, but the patient 
declared he felt very comfortable this morning, except for a 
kind of oppressive heaviness near the lower part of both lungs. 
Indeed, he felt so easy that he insisted upon having the barber 
come to shave him. At 6 a. m. the temperature had been at 
100°; about the middle of the forenc n I found it to be 101° 
and the pulse at 76, full and strong. A slight headache only 
was complained of. The lungs seemed to he clearing up, and 
the heart showed no signs of weakness. I stopped the brandy 
as well as the aconite and opium drops. Nourishment was 
urged every two hours, and I ordered the application of a large 
flaxseed poultice on the lower part of the lungs, a Seidlitz 
powder, two grains of quinine every twTo hours, and a dessert- 
spoonful of the follovving combination every three hours: 
IJ Ammon, carb gr. lxxx ; 
Pulv. acac. et sacchar aa q. s. ; 
Sp. lavandul. comp 3 ij ; 
Aquae ad § iv. M. 
19th.—The patient had four quite loose stools since the day 
before. There was no pain about the chest and scarcely any 
headache, but he complained somewhat of the fullness of the 
lungs and the ditficulty he had in breathing. The dullness on 
percussion was still quite marked about the base of the left 
lung; somewhat less so over the same area of the right lung. 
I again cupped the chest freely, and ordered the flaxseed poul- 
tices to he changed every fifteen minutes. The quinine pills 
and ammonium-carbonate mixture were continued, and the fol- AND THE CAUSE OF HEART FAILURE. 
5 
lowing suppository used at 10 a. m., 4 and 8 p. m., and 6 a. m. 
the next morning: 
5 Pulv. opii gr. ss.; 
Quinin. sulph gr. x; 
Oh theobrom q. s. M. 
20th.—The patient was much easier than the day before. 
The pulse and temperature registered 78 and 100’5°. The pul- 
monic dullness was still marked, while expectoration streaked 
with slight rusty sputum was beginning to be freer. The dull- 
ness at the base of the right lung seemed to be increasing, while 
that of the left side was diminishing. 1 continued the use of 
the poultices and suppository, and ordered the following mixt- 
ures to take the place of the quinine pills and ammonium car- 
bonate : 
5 Potas. iodid 3 ij ; 
Ammon, chlorid 3 jss.; 
Mist, glycyrrliiz. comp vj. 
M. Sig. : Tablespoonful four times a day. 
f* Pulv. digitalis gr. ss.; 
Quinin. sulph gr. j; 
Ext. opii gr. ss. ; 
Ext. ipecac gr. J. 
M. et ft. in pil. no. j. 
Sig.: One three times a day. 
A small quantity of stimulus was allowed when there was 
marked weakness. 
21st.—The patient expectorates freely, there is no more 
blood in the sputum, the pulse is full and regular, and the tem- 
perature marks 99-5°. Breathing is easier, and, in his own 
words, he “feels fifty per cent, better than ever.” Same treat- 
ment continued. 
22d.—Both pulse and temperature were normal this morn- 
ing. Expectoration was free and appetite rapidly returning. 
The only change made in the treatment was the omission of the 
suppositories. So well, apparently, was the patient that, al- 
though I x'ecommended quiet and rest in bed for a few days 
longer, I said I would not call as frequently, but left word that 
they should send for me immediately if any unusual symptoms 6 
SOM8 REMARKS OX PNEUMONIA 
made their appearance. I was in doubtful anticipation of the 
crisis. 
About 5.30 p. m. I was hurriedly summoned and found that 
the patient had experienced, about an hour previous, a violent 
chill and a sudden feeling of impending death. His features 
showed alarm, although he was somewhat stupid and indiffer- 
ent. He was covered with a cold, clammy sweat. The respira- 
tion was slow, regular, and labored. The pulse-beat was 58 
and full, while the temperature continued to be normal. The 
lips were pale, the extremities cold, and the eyes dark and 
sunken. I recognized the condition as critical heart failure. 
The lungs upon examination were found to be comparatively 
clear. The heart was hypertrophied, probably as the result of 
the three or four previous attacks of pneumonia which the 
mother now told me he had passed through, but in none of 
which he had experienced the sudden prostration of this attack. 
In consultation, Dr. II. H. Deming confirmed both my opinion 
and treatment of the case. I at once stopped all medicine save 
the ammonium carbonate mixture, and increased the amount of 
alcoholic stimulants. At 1) p. m. there was another violent chill, 
longer than the first, more prostrating, and followed by the 
same cold sweat, which quite wet the bed-clothing. The accom- 
panying stupor was also the same as that following the previous 
chill. The anxiety and nervous depression were extreme. The 
pulse was weak, thready, and beat 50 to the minute. Hot bot- 
tles were placed in the bed and half an ounce of whisky in 
water given every hour. The ammonium-carbonate mixture 
which had been ordered on September 18th was resumed, and 
administered every three hours, together with the following 
pill every six hours: 
R Pulv. digitalis gr. ss.; 
Quinin. sulph gr. j ; 
Ext. gentian q. s. M. 
Remaining with the patient myself the greater part of the 
night, I devoted all my attention to stimulating and sustaining 
the heart's action. 
23d.—Called at 7 a. m. and found much less nervous depres- 
sion, though an extreme degree of physical weakness. There AND TDK CAUSE OF HEART FAILURE. 
7 
was no cough. The respiration was slow and labored, the pulse 
50, and the temperature 97‘80. The medicinal treatment was 
continued with free stimulation. Nourishment in small amounts 
was allowed every hour, consisting of milk with lime water, 
beef tea, mutton broth, milk toast, jellies, etc. 
2Jf.th.—At 8 a. m. the condition of the patient exhibited a 
marked improvement. He was brighter and stronger. The 
pulse varied between 55 and 60. The surface of the body was 
warmer and there were no more chills, though he continued to 
perspire abundantly. In place of the digitalis pill which he had 
been taking, I ordered the night before the following prescrip- 
tion, to which I attribute the decided change for the better this 
morning : 
H Strychnin, sulph gr. ; 
Tinct. digitalis gtt. v; 
Tinct. gentian comp ad 3j- 
M. Sig.: To he taken every six hours. 
The nourishment consisted of milk, beef tea, broths, toast, 
calves’-foot jelly, and Parke, Davis, & Co.’s haemoglobin com- 
pound in teaspoonful-and-a-half doses three times a day. 
25th.—The condition about the same. Every two hours 
some nourishment with an ounce of whisky was given. The 
ammonium-carbonate mixture was continued every two hours 
and the strychnine administered every four hours. 
26th.—The patient passed a comfortable night and slept 
well. He took about a quirt of milk, a full cup of beef tea, and 
the haemoglobin compound. About 3.80 p. m. to-day there was 
another chill, not so severe as the previous ones, but followed 
by the same profuse perspiration. The temperature registered 
97° and the pulse 52. There was no difficulty of breathing, no 
cough, but excessive prostration. I ordered the whisky in 
half ounce doses every hour, the ammonia mixture every two 
hours, the strychnine every four hours, and an addition to the 
diet of some cup custard with a soft-boiled egg the following 
morning. 
27th.—The patient slept soundly, hut awmke feeling chilly 
and bathed in a profuse perspiration. His general condition re- 
mained about the same. The temperature was 98°, the pulse 8 
SOME REMARKS OX PNEUMONIA 
52. The appetite was reviving and he was allowed to-day a 
small piece of mutton chop and some milk toast. The same 
medicinal treatment was continued. 
From this time on there was nothing of special moment 
either in the character of the case or its treatment. Occasion- 
ally there would be a slight chill followed by a profuse sweat. 
The pulse continued to remain at 52, and the temperature fluctu- 
ated between 97° and 98°. The diet was closely watched 
and cautiously increased. The stimulants and medicines 
pushed, changed, or withdrawn as the conditions seemed to 
require. 
October 2d.—The pulse was still at 52 and the temperature 
97°. Patient ate some ice-cream upon his own responsibility 
and had a slight attack of colic. He now took three regular 
meals a day, an ounce of whisky every two hours, the strych- 
nine every four hours, and a teaspoonful of the following com- 
bination after each meal: 
H Pepsin in lamel. (P. D. & Co.) 3j; 
Acid, hvdroch. dil § ss.; 
Syrup, limon 3 ij ; 
M. Aquas ad §iij. 
3d.—The pulse steadily rose to 68 to-day. Stimulants were 
gradually withdrawn. General tonics with cod-liver oil and 
maltine were prescribed. A day or two later the patient began 
getting out of bed, and on October 10th he called at my office 
perfectly well but very weak. 
This case, which, as I have said, is not presented on ac- 
count of any unusual features, affords several lessons, and 
therefore I report it as a text for the following remarks : I 
have long’ been convinced that croupous pneumonia is a sys- 
temic disease with a local manifestation in the lungs. It 
attacks the individual suddenly and its first effects are felt 
throughout the whole constitution. Its nervous manifesta- 
tions especially ally it to the other specific constitutional af- 
fections. It is certainly not a simple inflammation, as proved 
by very many of its characteristics, and especially by the re- AND THE CAUSE OF HEART FAILURE. 
9 
suits obtained when a line of treatment is adopted in accord- 
ance with the idea of its being an inflammation. Were it 
an inflammatory disease there would have been formulated 
long ago a method of treatment more universally adopted 
than any now employed. The late discussions and com- 
parisons among the physicians of Paris in regard to the 
treatment of pneumonia revealed a most lamentable uncer- 
tainty of knowledge. Each reporter vaunted his own meth- 
od, and scarcely two were found to exhibit any sort of agree- 
ment. As has been pointed out by various experimenters, 
the inhalation of hot and cold vapors and noxious gases, the 
injection of caustic ammonia and mercury, as well as trau- 
matic injuries, all produce catarrhal but never croupous pneu- 
monia. The bacterial origin of the latter has the support 
of the strongest arguments, but the nature and influence of 
the micro-organisms are yet far from being established, 
despite the popularity of the pneumococcus of Friedlander 
and Talamon. Though pneumonic fever is to so large 
an extent a terra incognita, there can scarcely be any 
doubt entertained at the present time in regard to its spe- 
cific origin. Its remarkable similarity to many of the other 
specific and self-limited fevers lends powerful support to 
this view. 
I do not believe that true croupous pneumonia can be 
aborted by any known therapeutic agent, though the sever- 
ity of many of its symptoms may be greatly abated by judi- 
cious treatment. Very early in the disease I employ the 
opiates and even such heart depressants as aconite and ve- 
ratrum to allay the pain and to modify the circulation, but 
l always do so with the greatest caution and only in sthenic 
cases. The pathological state of the blood, the frequent im- 
plication of the pleura and pericardium, the congestion of 
the bronchial glands, liver, spleen, and other organs, the oc- 
casional gastro-intestinal catarrh and cerebral congestion, as 10 
SOME REMARKS ON PNEUMONIA 
well as the peculiar location of the pneumonic process at the 
base of the lungs, all seem to me to indicate a poisoned con- 
dition of the general circulation. There is a strong proba- 
bility that a ptomaine or other toxic substance is boating 
in the blood, and, through its baneful effects upon the nerv- 
ous system, is the real cause of the disease. As Loomis says, 
“ in local phlegmasise there is a direct ratio between the 
amount of surface involved and the attendant constitutional 
disturbances.” Here, however, there is no sort of a paral- 
lelism between the inflammation in its character or its ex- 
tent and the fever and other symptoms which accompany 
it. It follows, therefore, that until we And some specific 
remedy capable of neutralizing this poison in the blood, the 
treatment of croupous pneumonia must be largely symptom- 
atic. 
Those who attempt to formulate a method for all 
cases alike seem to me to be traveling a wrong road. In 
the present state of our knowledge, at all events, we must 
regard each case by itself, study all its individual peculiari- 
ties, and treat particular conditions as they arise. Some 
cases of extreme severity will do well upon one or two reme- 
dies persistently administered throughout the entire course 
of the disease. Others will demand a daily, almost an hour- 
ly, modification of the treatment to carry them to a success- 
ful issue. And that physician will secure the best results 
who is the quickest to comprehend the true pathological 
state at the moment, and who is most completely equipped 
with the knowdedge of a materia medica capable of combat- 
ing that particular state. Especially should it be remem- 
bered that the disease is a specific, self-limited one, that its 
chief force is manifested in the depression of the nervous 
system, and that therefore the strength and vitality of the 
patient must be supported above all other considerations. 
The case which I have reported demanded a varied treat- -AND THE CAUSE OK HEART FAILURE. 
11 
ment, and 1 believe the fortunate result in one who had so 
little physical strength previous to the onset of the disease 
is to be attributed largely to the tiinelv modification of the 
remedies employed and the free stimulation when the heart 
began to give out. 
My own observation leads me to disapprove of the use 
of the cold pack and the phenol group of antipyretics in this 
disease. The nervous depression is far too great to endure 
the extra depression which these therapeutic agents are lia- 
ble to add. In fact, 1 do not believe that the fever is itself 
so dangerous an element as the nervous exhaustion caused 
by the noxious infiuence of the toxic substances in the blood. 
1 am sure a moderate control of the temperature is all that 
is necessary, and that this control can be obtained to a very 
large extent by the proper stimulation and nutrition of the 
patient. As in the other specific self-limited diseases, the 
maintenance of the vital processes by an abundant selected 
diet should be the prime object in the treatment. In regard 
to the choice of stimulants, I usually employ alcohol, nux 
vomica, and strychnine as my favorites. In some cases digi- 
talis seems to act beneficially and strophanthus more so, but 
I have learned that it is unwise generally to depend upon 
them alone. Nux vomica and its alkaloid are both respira- 
tory and cardiac stimulants, and when administered in full 
dosage as often as the conditions require, I believe they will 
afford the happiest results. 
The above case, as well as many others, establishes 
to my mind the fact that the heart failure of pneumonia 
is not due to the high fever and lung obstruction, as 
contended by many of the systematic writers. These 
factors may operate in a certain few cases, and to a lim- 
ited extent may have an infiuence in all; but there are 
many impressive facts telling in direct opposition to such a 
view. 12 
SOME REMARKS ON PNEUMONIA 
In the first place, the fever of pneumonia is rarely a pro- 
longed high fever. It certainly is not as long or as severe 
as the fever of many other diseases in which heart failure 
never occurs. The prolonged high temperature of typhoid, 
for instance, is so debilitating as to affect the whole organ- 
ism. The general muscular deterioration of pneumonia is 
quite marked, and yet the parenchymatous elements of the 
heart, as shown in post-mortem examinations, do not seem 
to be degenerated any more than the rest of the system. 
It is difficult to comprehend how a general pneumonic fever 
could exercise such a selective action upon the heart if we 
were to accept the doctrine that the weakness of the 
heart is due to the fever alone. The heart failure, fur- 
thermore, bears no proportionate relation to either 
the extent or severity of the pulmonic lesion. It is 
frequently quite as rapid and fatal in cases where the 
autopsy reveals disease of one lobe as where both lungs are 
affected. 
It is sometimes said that the fever merely weakens the 
heart, while the extra work imposed upon that organ in 
forcing the blood through the consolidated lung tissue 
causes it to collapse. This may he true in some instances, 
but in very many, of which the case reported is a fair ex- 
ample, the heart does not fail until there is a marked sub- 
sidence of the fever and the lung is beginning to clear up. 
Heart failure may exist before or just when the hepatiza- 
tion of the lung is commencing, and, as Loomis has already 
pointed out, in many other pulmonary affections there is far 
greater obstruction to the circulation than there is in pneu- 
monia, and yet they are not accompanied by heart failure. 
As in the matter of the high temperature, so here it may 
be argued that there is no proportionate relation between 
the heart failure and the amount of lung tissue obstructed. 
In my own case only a comparatively small area of the AND THE CAUSE OF HEART FAILURE. 
13 
lungs was originally affected, and this was beginning to be 
clear again when the heart broke down. It is difficult to 
conceive also liow the hepatization of the lung should cause 
so much extra work for the heart, when during the con- 
gestive stage of the disease the blood-vessels were over- 
charged, and yet the action of the heart was then increased 
rather than diminished. In the consolidation stage of the 
process the blood-vessels are usually beginning to be relieved 
of their extra pressure and the circulatory congestion is on 
the decline. The air cells of the lungs now become the 
overcrowded elements. Hence, in this stage there is 
marked percussion dullness and an increased sense of suf- 
focation ; but this has all been brought about at the ex- 
pense of the previously engorged blood-vessels. The blood 
stasis is compensated, to a certain extent, by the subsequent 
oedema and transudations. There will be less oxygenation 
of the blood on account of the diminished supply of air in 
the lungs, but it is hard to see just how such a state of af- 
fairs could produce a mere mechanical obstruction to the 
tlow of the circulation greater, or even as great, as that of 
the early congestive stage of the disease. If we divide ex- 
perimentally the cervical portion of the pneumogastric nerve, 
the lungs undergo a process of hepatization or consolida- 
tion which is not associated with heart failure. And yet it 
is just at the time when hepatization is going on, and not 
infrequently after it has begun to recede, that the heart 
ceases work. 
Another objection to this mechanical explanation of the 
heart failure of pneumonia is the suddenness and periodicity 
with which this unfortunate event takes place. This was 
illustrated most forcibly in my own case. One would im- 
agine that as the heart muscle grew gradually weaker under 
the extra strain, and the lungs became more impenetrable 
under the consolidation process, the failure of the heart 14 
SOME REMARKS ON PNEUMONIA 
would proceed pari passu. But such is not the case. The 
crisis of the disease occurs more or less regularly at a fixed 
time and is a comparatively sudden event. In no other dis- 
ease is there a crisis comparable to that of pneumonia. 
Other affections have their periods of activity terminated 
more or less abruptly by death or the beginning of con- 
valescence, when the patient has perhaps reached a state of 
profound exhaustion, but in pneumonia the crisis is a 
unique process. All the symptoms continue unabated until 
a certain period has elapsed, and then in a comparatively 
sudden, sometimes appalling, manner a complete collapse 
occurs, with a rapid and remarkable decrease in the tem- 
perature and pulse-rate. The picture is not of such a char- 
acter as to suggest a mechanical explanation; it intimates 
rather a sudden addition or withdrawal of something ab- 
normal in the circulation. The influence of this something, 
whatever it may be, is shown pre-eminently through the 
nervous system. Many think that it is a ptomaine thrown 
into the blood by the pneumococcus, and that this ptomaine 
irritates the pneumogastric centers and so causes this nerve 
to exert an undue inhibitory action upon both the lungs and 
heart. We know from an examination of the urine that 
more urea is excreted and that other deleterious substances 
are retained in the blood that are normally eliminated by 
the kidneys. As the retention of these poisons in the cir- 
culation, however, and the production of the ptomaine by 
the pneumococcus commence, in all probability, with the 
commencement of the disease, the question will have to be 
answered as to why then the heart failure is postponed so 
long. It is a fact that the heart begins to pulsate irregu- 
larly from the very beginning of the disease—so much so 
that heart insufficiency has been detected by the variations 
of the pulse within twenty-four hours of the onset of the 
pneumonia. This is strong presumptive evidence of the AND THE CAUSE OF HEART FAILURE. 
15 
heart trouble being due to the appearance of a particular 
poison in the blood, but, as I have intimated, it does not 
satisfactorily explain the sudden heart failure that occurs 
about the crisis of the disease. It is this latter fact that 
needs further elucidation for the complete solution of the 
problem. Furthermore, the explanation is wanting as to 
the selective action of these poisons upon the pneumogastric 
nerve and nuclei. If they irritated that nerve, it is quite 
rational to suppose that they irritate all the nerves of the 
vaso-motor system. The cardiac ganglia would thus feel 
the same influence as the respiratory and cardiac centers of 
the medulla. The motor and inhibitory apparatus would be 
similarly affected, and thus a kind of compensation would 
be established which we might look to to prevent the usual 
suddenness of cardiac failure. 
The same brief objections seem to me to apply to the 
explanation presented by Loomis in Pepper’s System of 
Medicine and based upon physiological data. This writer 
argues that the toxic substance in the blood affects the 
tonic properties of the vaso-motor system of nerves, so as 
to allow an undue accumulation of blood within the capil- 
lary vessels and arterioles ; and as this blood is not returned 
to the heart, there results a diminution of pressure so great 
as in itself to cause heart failure. The periodic appear- 
ance of the crisis and the comparative abruptness of its 
phenomena, chief of which is the heart failure, seem to 
me to have been entirely overlooked in this explanation. 
Professor Loomis admits that the morbific agent may 
act upon the intrinsic cardiac ganglia as well as upon 
the medullary vaso-motor centers. This, as we have said, 
will doubtless derange the strength and regularity of 
the heart’s action. It will produce, however, a sort of 
compensation between the augmentation and inhibition of 
that action. 16 
PNEUMONIA AND CAUSE OF HEART FAILURE. 
To sum up, then, I believe that the origin of the whole 
trouble is a poison floating in the blood and irritating the 
nerves and nervous centers. The true nature of this poison 
is as little known as that of many of the other specific con- 
stitutional diseases. All explanations of its modus operandi 
must be conjectural until we learn more of its nature. I do 
not believe that it consists simply of the uneliininated mat- 
ters of the blood, for in uraemic poisoning and other dis- 
eases accompanied by diminished elimination we do not 
have exactly the same phenomena that we do in the crisis 
of pneumonia. It is a new substance, and in all likelihood 
a ptomaine produced by some micro-organism in the lungs. 
This ptomaine begins to affect the nervous system from the 
very beginning of the disease, and so causes its constitu- 
tional disturbances and general symptomatology. It affects 
all the nervous elements alike, modifying the regularity of 
their functions, and, for a time, maintaining a kind of com- 
pensation between motor and inhibitory forces. This, of 
course, exhausts all the tissues involved. About the time 
of the crisis of the disease, if the process does not extend, 
the micro-organisms cease to pour their poisonous products 
into the blood because the cycle of their life history is 
ended. The influence of these products is thus suddenly 
withdrawn, and the heart, being therefore deprived of that 
which, up to the crisis, had been overstimulating and other- 
wise injuriously affecting it, collapses. This, it seems to 
me, is, in a few words, the simplest explanation of the heart 
failure of pneumonia. No one can tell, however, how soon 
changes may be necessary in all or any explanation as a 
result of future discovery. 
4228 Greenwood Avenue. REASONS WHY 
Physicians Mi Sntissrfte 
-FOK- 
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