Probably all febrile conditions are attended by a state of toxaemia, but there are other toxaemias which are afebrile.
Amongst the febrile conditions we have all the infectious troubles including pneumonia, typhoid, etc. In a vast majority of these cases death is, more or less, directly due to cardiac failure. The old adage says, "Stuff a cold and starve a fever," but we find that in many of the cases now under consideration starving is a most unwise policy. Most of us have seen cases of pneumonia, and other septicaemias which owe their recoveries entirely to their extraordinary powers of taking nourishment, whilst, on the other hand, cases are often met with in which we see the inability to take nourishment well inevitably followed by cardiac failure. The dietetic treatment of fevers, etc., will receive attention elsewhere, and we need do no more here than emphasize the importance of the use of plenty of suitable nourishment, as a preventive of cardiac failure in such cases. The dry, unwholesome state of the mouth and lips in febrile cases is often a cause of the anorexia, and careful attention to their toilet will frequently increase the amount of food taken. Another important point is the regulation of the diet so as to prevent what is so common in many cases, viz., abdominal distension. This condition is apt to occur in all febrile and toxaemic states; it is necessary, therefore, to use great care to prevent the nourishment increasing this tendency, because the pressure caused by the consequent raising of the diaphragm is a potent element in bringing about cardiac failure. The diminution or total withdrawal of aerated waters may be all that is necessary in some, whilst the peptonizing of all the milk taken may have to be resorted to in other cases. The discontinuance of all medicines by the mouth is often of importance, so as to leave the stomach undisturbed by possibly irritating drugs. All necessary medication must be carried out subcutaneously or per rectum. Great care must be used in the supervision of the milk, its storage for instance, and to see that it is alkaline when given. The addition of lime-water, bicarbonate or citrate of soda, to the milk will often help in its digestion. Sometimes the substitution of junket, or curds and whey, or whey only, with or without the addition of a little cream, is found helpful: or it may be necessary to discontinue milk altogether, giving weak meat, veal or chicken broths instead. It seems sometimes as though the copious use of fluid food is the direct cause of the abdominal distension; concentration of the milk by evaporation will, in some cases, be found effectual in removing this troublesome condition and so in relieving cardiac symptoms. The giving of solid food too soon, however, is another cause of distension, and its occurrence should warn us of the necessity for returning to fluid food for a time.
In considering the afebrile toxaemias, mention must be made of the cardiac failure attending the last stages of such diseases as hepatic cirrhosis (cholaemia?) Bright's disease (uraemia?), diabetes (acetonaemia?) and Addison's disease. One must refer the reader to the articles on these diseases for their treatment. The cardiac failure, in all of them, is more manifest towards the close of the case, when dietetic treatment can be of but little avail.
This seems the best place to consider the treatment of the heart trouble occurring with exophthalmic goitre. It is a noticeable feature in this disease that a hopeful issue may almost always be expected so long as the patients do not waste. The disease is characterized by periods of activity alternating with periods of quiescence, during which symptoms are more or less in abeyance and an ordinary active life can be led by the patient.' During the quiescent stages, as a preventive, but especially during the active stages, rest and generous feeding are important points in the treatment, indeed a modified "rest cure," with all its increased nourishment, is the best means at our disposal for treating the active stages and distressing cardiac symptoms of this disease.