walls of his heart by muscular effort? I believe that one can speak
with some confidence on this subject. The middle-aged patient who
over-stretched his cardiac walls as a youth may be comforted with
the opinion that the condition is not a fatal one. The average
duration of 11 cases of this order I found to have been 30 years
when they came under my observation; the minimum duration was nine
years, the maximum 50 years. This last case deserves particular
mention. The patient was first seen by me for failure of the heart
with cardiac dropsy, consequent on fresh breakdown after exertion
during a holiday; and it is most encouraging to observe that
compensation was restored by treatment, and that now, 12 months
after that event, he is not only alive, but able to carry on light
professional work. This case also illustrates what I have told you
respecting the course of the affection, and the prospect before the
patients, in long-standing strain--that there is continual liability
to fresh embarrassment of the heart during exertion, in which they
appear to have a lasting inclination to indulge. If they happen
to follow an occupation that entails occasional effort, or effort
with excitement and worry (if they happen, let us say, to be busy
practitioners of medicine), they suffer in the same way from attacks
of tachycardia, distressing palpitation and anxiety. Indeed, as I
pointed out in my second lecture, they are readily upset by other
influences besides these, including indigestion, to which the victim
of hurry and worry is peculiarly liable; and they must be prepared
to have to lead a life of comparative temperance and self-denial.
Neither is strain of the heart for the first time after 40 by any
means so grave as might be expected. Of course, sudden muscular
effort occasionally accounts for sudden death in old men. But it
is astonishing how, under such circumstances, quite old persons do
recover from conditions of extreme distress lasting acutely for
half an hour--for instance, after running with a heavy bag to catch
a train. The majority of my patients described their condition as
improved after a time, but others relapsed; and on the whole the
correct prognosis is that they must expect to remain variously
disabled--that is, liable to præcordial distress and dyspnœa on
more than moderate exertion, or when subjected to circumstances of
other kinds that tax the heart.
Cardio-vascular disorder and disease referable to nervous strain
pure and simple is amenable to treatment by complete and prolonged
rest or relaxation in the majority of instances. Still, death may
occur from sudden cardiac failure; or should advice be neglected
or soon forgotten, as happens so frequently in these subjects,
the attendant high arterial tension and vascular degeneration too
often end in cerebral lesions, with or without Bright's disease. Of
chronic Bright's disease itself and the associated cardio-vascular
changes in their prognostic aspects I need not speak, except to say
that along with syphilis it is by far the most hopeless of all these
affections.
In attempting to forecast the life of a man who is the subject of
cardio-vascular degeneration in middle or advanced life, we must
not forget the possibility of the intercurrence of acute disease.
Here is a large subject for us as practical men--one far too large
and important for discussion here: the effect, for instance, of the
existence of enlargement of the heart and an irregular and thickened
pulse on the prognosis of influenza, or, let us say, on the chances
of a successful issue after operation. Very naturally, unsound
vessels and a murmur over the præcordia weigh heavily against the
prospect of recovery from pneumonia, for example; and yet how often
do we not find a patient of 70 with one or both of these disturbing
conditions come safely through such an illness! Here, again, I
believe it is in great measure the true nature of the old-standing
disease, not the physical signs such as irregularity of pulse or
mitral bruit, that ought to be taken into account. A heart enlarged
and a radial artery thickened by prolonged activity and nothing else
will suffice to carry a man safely through an attack of influenzal
pneumonia; but what chance is there for the chronic alcoholic under
similar circumstances, or for the subject of chronic Bright's
disease?
So much for the general prognosis in each of these kinds of
cardio-vascular disorder and disease. But it is the particular
prognosis that we have to attempt to estimate--that is, the
prognosis in the individual patient as he comes before us and
asks us that trying question, "What is my prospect of life and
health"? We diagnose, if possible, the precise nature of his cardiac
affection, and apply to the best of our ability the conclusions
which I have just submitted to you, and at the same time we estimate
as correctly as possible the man's personal condition, character and
disposition. For, whatever may be determined with respect to the
average patient by an analysis of a large number of these cases, the
individual patient's future in disease of the heart of every kind,
degenerations included, greatly depends on the care that he takes
of himself. This introduces us to another consideration. However
earnestly we may attempt to estimate the prognosis on a strictly
rational system--that is, by basing it on an accurate and complete
diagnosis--we cannot deny that when the individual patient is before
us we are influenced directly by certain of the symptoms and signs,
without asking ourselves what their respective pathological meaning
may be. True bradycardia, the story of an unmistakable attack of
angina pectoris, a loud aortic diastolic murmur, the _bruit de
galop_--these instantly give us great concern before we have had
time to translate them into the language of morbid anatomy. Very
naturally we attempt to carry this method too far, and to reach a
prognosis, as it were, by a short cut, by attaching a prognostic
value to each clinical phenomenon--palpitation, præcordial
oppression, faintness, lethal sensations, and so on. Now, quite
irrespective of the unscientific character of this proceeding, it
is of little practical service. Even when we have listened to an
account from a middle-aged man of an attack of angina pectoris,
what can we tell him of his prospect of life until we have learned
whether he be guilty of excessive smoking or drinking, whether he
be gouty, whether he have lately strained his heart or no? What
I do regard as really valuable prognostically, in the way of a
simple clinical observation, is the determination of progressive
symptoms and signs. A man of 72 complains of oppression over the
lower sternal region as often as he climbs a hill. Twelve months
later he comes and tells us that he has had an attack of severe pain
across the top of the chest during the night. Another year passes,
and he returns to say that now he cannot hasten on the street
without præcordial distress; and it is noted that the second aortic
sound, previously thick in character, is slightly blowing. By the
fourth year of observation the patient, having had influenza in
the interval, complains of an auto-audible murmur, and of actual
pain in the chest; there is now a fully-developed aortic diastolic
murmur, and his ankles swell occasionally. Prognosis was only too
easy in this case, without inquiry into either the cause or the
lesion. A few months later true angina occurred, and very shortly
the patient died, after twenty-four hours' severe suffering.
TREATMENT.
Not the least advantage of the etiological standpoint of our
survey of the disorders and diseases of the heart and arteries
in middle and advanced life is the rational as well as hopeful
line of treatment which it enables us to pursue. On the whole,
we can control morbific influences more easily than we can alter
pathological processes; and (what is of equal or even greater
importance) a knowledge of the causes of disease often enables us to
prevent what we could not possibly cure. For all that, the etiology
of heart disease furnishes us with but one set of many invaluable
indications for treatment. We must have also a clear mental picture
of the pathological anatomy of the conditions we would attempt to
modify--for instance, of the damage wrought by gout on the mitral
valves and aortic arch, by syphilis on the coronary arteries, by
strain on the walls of the different cardiac chambers. No less
necessary is it for the practitioner to take into account, before
proceeding to prescribe, the clinical characters and course of
the case in hand. As I have said more than once already, a large
proportion of the distress, disabilities and dangers attending
degeneration of the heart are due to some additional or extrinsic
disturbance--distension of the stomach, constipation, worry or
exertion--which alone, not the pathological condition, calls for
therapeutical attention.
It appears, then, that the whole natural history of the diseases
and disorders of the heart--and, I might add, of every individual
case--has to be studied, and the value of its different parts
absolutely and relatively estimated, before rational treatment can
be ordered. How different will treatment be, if ordered on these
principles, from the routine procedure of prescribing a little
strychnine and digitalis for a man with oppression on exertion and a
systolic bruit at the base of his heart!
Let us begin this part of our subject with a brief consideration of
preventive treatment, founded on a knowledge of the cause at work.
Now, the first thing to strike us about these unfavourable
influences is the number of them that could be avoided or controlled
successfully by simple exercise of the will. The toxic effects of
tobacco, alcohol, tea, &c. are due to abuse, from thoughtlessness or
ignorance, or from indisposition rather than inability to exercise
self-control. The abuse of tobacco appears to create so much
discomfort or even alarm, of a kind which the sufferer cannot fail
to refer to its cause, that the remedy is effected automatically,
and no great harm is done. We seldom have to do more than confirm
the patient's suspicions in this direction, and recommend temporary
abstinence from the cigarette or pipe and greater care in the
future. With alcohol it is a different matter. Alcoholism grows by
what it feeds on, and our best efforts are often vain. The present
is hardly an occasion for dwelling on this subject--the duty of the
profession to their patients and friends in respect of the abuse of
alcohol. Still, I should not feel that I had discharged to the best
of my ability, or in full conformity with my strong convictions,
the duties of the honourable position which by your favour I
occupy as Lettsomian Lecturer, if I did not urge you to exercise
more fully than is at present exercised your personal influence to
discourage habitual drinking. I believe (because I have found) that
many men who are not open to arguments of an abstract kind, can
be made to pause and reconsider their manner of living by having
a concrete presentment of their condition and its results placed
before them--in plain English, by being thoroughly frightened.
"Heart disease" is a powerful argument to employ with persons of
this class, and it is one that is also justified by the issues at
stake. Of syphilis and the havoc that it works on heart, aorta and
the vascular system generally, but particularly within the nervous
system, I need not speak. The profession, as I have said, is not
yet sufficiently alive to it: what can the public be expected to
do in the way of prevention? Gout, corpulence and allied metabolic
disorders, those fruitful sources of cardio-vascular disorders and
atheroma, call for temperance not only in drinking but in eating.
Whilst the question continues to be discussed which particular
articles of food ought to be avoided by gouty individuals, let us
all join in offering them one bit of advice of the value of which
there can be no doubt: whatever they eat, to eat little. Moderation
in amount is, speaking broadly, far more important than avoidance of
the theoretical antecedents of uric acid, whether meat, or milk,
or sugar. Let me quote what Dr. George Balfour, who has written so
much and so well on disease of the heart and its treatment, says on
this subject:--"I know of no society that inculcates, by precept or
example, temperance in regard to food; yet there is nothing ages a
man or a woman so rapidly, there is nothing that shortens life so
certainly, and there is nothing that embitters the latter days of
life so much as over-indulgence in food. To those who can afford
thus to transgress--to the well-to-do--excess in food is a much
more serious menace to health and life than excess in drink, and
it is specially so in respect of senile affections of the heart,
some of which have been distinctly recognised to owe their origin
to over-indulgence, while all are distinctly aggravated by it."[15]
With the observance of this simple and wholesome dietetic rule must
go attention to free elimination by all the excretory channels, and
the insurance of sufficient exercise and enjoyment of fresh air.
If we wish to impress this consideration on our own minds and give
effect to it in our practice, let us call to mind for a moment the
number of cases that I have submitted to you of atheroma of the
aorta in stout matronly women of sedentary and luxurious habits, in
whom, indeed, this degeneration is quite as common as in men.
[15] G. W. Balfour, 'The Senile Heart,' p. 236, 1894.
I have already said so much on the subject of cardiac strain that
it is unnecessary and would be uninteresting to return to the
question of the prevention of it. We have seen how often it occurs
in the middle-aged or old subject by ill-considered attempts at
athleticism. Moderation and due respect for age are the true
guides to the useful enjoyment of exercise after 40. As for the
evil effects of nervous influences on the circulation, in addition
to anxiety, care, misfortune and grief, which are usually beyond
our control, nervous strain, as distinguished from simple hard
intellectual work, often must be relaxed if cardio-vascular damage
is to be prevented. I refer to the cases of persons in positions of
great responsibility with heavy complex prolonged duties, which they
fail to overtake without exhaustion consequent on high pressure and
excitement.
* * * * *
I would not have dwelt so long upon the measures calculated to
prevent degeneration of the heart, were it not that they have to be
employed with equal strictness and perseverance in the treatment
of cardio-vascular disease when it is already established and our
assistance is sought with anxiety. The etiological indications have
still to be respected faithfully; on this I need not dwell. The
next question is:--What can be done for the pathological changes
wrought on the arteries and the valves and walls of the heart? In
syphilitic lesions we do not hesitate to say that potassium iodide
should be given freely: it is a specific remedy of great value.
Can the atheromatous process be influenced with equal or with any
success? It depends on toxæmia and anæmia; the obvious indication is
to purify and enrich the blood. This, at least in respect of gout,
glycosuria and corpulence, as we have just seen, must be effected by
a thorough reform in every department of personal hygiene. Arsenic
and moderate doses of iodides, combined with an excess of alkalis,
are calculated to promote the same end. Dr. Mott has shown that
atheroma, whether of valves or of vessels, can be traced in many
instances to disease of the _vasa cordis_ and _vasa vasorum_. This
carries us a step forward in our quest for indications, but the
practical conclusion remains--that the healthy nutrition of the
smaller arteries has to be restored by attention to the blood and
the use of specific remedies.
So much for valvular and vascular lesions. There remains to be
discussed the fulfilment of the greater indication for treatment:
the one which directs and governs the employment of the most
important and successful of all the measures comprised in cardiac
therapeutics. This is the establishment and maintenance of
compensation. The nutrition and activity of the myocardium can be
increased and sustained by means of specific cardiac stimulants
and tonics, such as strychnine, ammonia and the digitalis group of
drugs; by hæmatinics, stomachics and laxatives to afford an abundant
supply of healthy blood; by insuring wholesome nervous influences,
one of the conditions of hypertrophy; and by the employment of the
non-medicinal measures now so extensively used to increase the
vigour and benefit the metabolism of the cardiac walls, particularly
active and passive exercises and baths. This is a comprehensive
statement of the lines of treatment calculated to benefit more or
less all the kinds of cardiac degeneration which I have had occasion
to notice. Of the individual pathological changes, and the rational
treatment indicated for each from this point of view, I will refer
to three only which will serve to illustrate the considerations
which ought to guide us in practice.
In the subject of regular or irregular gout attention to the cause,
that is, to disordered metabolism of the body as a whole and of
the cardiac and arterial walls in particular, promotes, as we have
seen, the recognised conditions of compensation: the etiological
and pathological indications are here practically identical. In
respect of exercise in detail, gentle walking on the level should
be ordered to begin with, that is, exercise short of producing pain
or oppression. The patient had better give up his regular work for
a time, and take advantage as fully as possible of the leisure to
enjoy the benefits of a healthy life in the fresh open air. Very
shortly he will be able to ride, play golf, shoot and cycle slowly.
A course of treatment at one of the best of our native spas or of
the Continental watering-places sometimes makes a new man of the
sufferer from gouty heart. The Nauheim treatment, whether taken
there or in England, may also do real good. But it must not be
employed indiscriminately, as is so often done. The profession
ought to remember (what the public cannot and probably never will
come to understand) that pathological diagnosis must precede
rational treatment, which consists in applying a proper remedy
to the individual case before us, not in fitting every case to a
specialised system or panacea--the essence of quackery.
In planning the treatment of the dilated heart of the
middle-aged man who strained his circulation in youth and comes
to us complaining of a recurrence of præcordial distress and
breathlessness, we have to remember that there is left in the
cardiac walls but a portion of that reserve of elasticity and that
reserve of muscular energy which they normally possess and require
to enable them to meet the stress of exertion. Let me remind you for
a moment that, of the provisions which the heart possesses against
such an emergency or other sudden or severe demand upon its capacity
and activity, one is extensibility of its tissues, by virtue of
which it accommodates within it the considerable increase in the
charge of blood that is poured into it from the active muscles, and
the residues that accumulate within it from insufficient discharge
in the face of increased peripheral resistance. The walls yield
before the increased internal pressure acting on them both _a
tergo_ and _a fronte_; the heart is over-distended, with a passing
sense of discomfort, dyspnœa and lividity; and when the muscular
effort is ended the elasticity corresponding with extensibility of
the walls presently insures the return of the chambers to their
original dimensions. At the same time a second provision comes into
operation. Increased muscular activity is developed in accurate
proportion to the rise of internal pressure and secures sufficient
output from the heart. This, I repeat, is what occurs in the sound
heart. Now, in old parietal strain extensibility and the reserve of
capacity of the chambers which it insures are seriously exhausted;
whilst the muscular function is only maintained by means of
hypertrophy, to which there is necessarily a limit. In these cases
of strain it is impossible to reduce the original dilatation--that
is permanent. But we may and ought to be able to reduce the further
dilatation, if any, that has been produced in connection with recent
failure of nutrition and fresh embarrassment. Therefore, whilst we
promote the nutrition of the elastic and muscular structures of the
myocardium on the general principles which I have just laid down,
we must be distinctly sparing of our demands on them. Everything
approaching effort must be forbidden at once and for a sufficient
time to rest and reinvigorate the cardiac tissues; whilst the
nitrites or small doses of opium will also give relief and restore
confidence in attacks of palpitation and anxiety. "Exercise, but
not exertion," will be the broad rule to follow, at any rate until
it has been proved that greater effort can be made with safety and
actual advantage. But if præcordial embarrassment be the result
of the attempt, or of ordinary professional work, as occasionally
happens, further rest will have to be taken, that is, rest for hours
or days, according to the severity of the symptoms. I have already
mentioned to you that middle-aged patients with cardiac strain,
dating from their youth, occasionally break down in their work for
months or even years. In such an event a thorough change of air
and scene should be combined with rest as a method of treatment. A
long voyage may prove invaluable, or foreign travel of an easy and
interesting kind. These not only rest the heart, but they divert the
mind and remove the curious nervousness or loss of courage which, as
I have said, is developed occasionally in these subjects, previously
so vigorous and confident.
Compare with this line of treatment that which is indicated in acute
cardiac strain after 40. The problem here is not how to deal with
a chronically dilated and hypertrophied heart, but with a heart
which has just yielded during effort, mainly in consequence of
the nutritional impairment of its walls. It is not simply strain
of a heart that had begun to be somewhat precariously nourished
as a natural result of age; the probability is that the heart
was actually gouty in the comprehensive sense of the term, that
is, irritated by uric acid and embarrassed by flatulence, both
mechanically and reflexly; and, indeed, possibly it was damaged
by the atheromatous process. Rest is essential at first in the
treatment of this type of case also; indeed, it is automatically
secured by the distress which accompanies attempts at movement.
But rest must not be carried too far, that is, it must not be
of greater degree or duration than is absolutely necessary as
indicated by the symptoms and signs, lest it aggravate the state
of parietal mal-nutrition and promote fresh gout. At the same time
the diet must be controlled strictly or even severely on the lines
that I laid down for gout, lest the over-feeding which accompanies
rest as a matter of thoughtless routine should have the same
unfortunate effects. A course of treatment at some of the good home
or Continental spas, with special precautions, is distinctly useful
in senile strain, and the Nauheim methods have benefited more than
one case of the kind in my experience, the degree of dilatation
diminishing whilst the vigour of the heart increased. At the same
time cardiac tonics of a medicinal kind are administered judiciously.