the myocardium, when it occurs to me that some of you might very
naturally ask me: What about fatty degeneration and the treatment
of it? This is a question peculiarly interesting to me. I have not
dwelt on fatty degeneration of the heart in these lectures, and yet
I have mentioned it again and again. I have said that it is a result
of alcoholism, of gouty atheroma of the coronaries, of syphilitic
arteritis in the same area, of Bright's disease, of profound anæmia
and of phosphorus poisoning; and that I believe it may result from
severe nervous strain of a harassing and depressing character; and
that in connection with each of these causes it has to be regarded
and treated differently. Nothing could well bring home more fully to
us the importance, indeed the necessity, of pursuing in practice the
line of inquiry, prognosis and treatment which I have advocated in
these lectures--the etiological one. Let me ask you also to listen
to a confession of one of the highest authorities on heart disease
in this country. "It is absolutely impossible," says Dr. George
Balfour, "to diagnosticate fatty degeneration of the heart; we may
surmise its existence, but we can only be certain of its presence
when we see it _post mortem_"; and he quotes Fraentzel of Berlin in
support of his statement.[16] It must have occurred to many of you,
as it has occurred to me, how seldom we diagnose fatty degeneration
of the heart until after sudden death. How can we be expected to do
so if we trust only to signs and symptoms, and overlook that which
is the key to the diagnosis--the discovery of the cause that is at
work?
[16] Balfour, _op. cit._, p. 249.
I have now sketched very broadly the rational treatment of these
disorders and diseases as far as the object of it is to prevent the
occurrence or the extension of them, and to promote compensation of
the disabilities which they produce. It remains for me to notice,
also very briefly, the management of cardio-vascular degenerations
when the heart fails, or when it appears to fail, and distress and
danger demand more direct and immediate attention. I have said
"when the heart appears to fail" of set purpose. I am anxious to
direct your attention, if it be but for a moment, to the fact that
in many instances where præcordial oppression, pain, palpitation
and faintness, with frequent small irregular pulse, are significant
of serious disturbance of the action of the heart, there is no
failure of the myocardium in the proper sense of the term, but only
embarrassment of a temporary character. Do not conclude from this
that I regard the disturbance of the heart as of little account. I
have called it serious, for indeed the patient may perish of it.
What I wish to maintain is that in cardiac degeneration of any
kind, in chronic cardiac dilatation, and in the enlarged heart of
Bright's disease and of emphysema, just as in ordinary valvular
disease, attacks of distress, alarming both to patient and doctor,
often occur which call for nothing more in the way of treatment than
attention to some intercurrent influence--an indigestible meal,
loaded bowels, a nervous shock, a thoughtless effort, a passing
hardship or nervous strain. Digitalis and its allies, strychnine,
alcohol, nitrites, iodides and the rest are out of place in such
an event. Complete rest in bed, a carminative draught, calomel and
saline purgatives, spare and highly digestible diet, reassurance and
a little time are quite sufficient means of treatment.
When true failure occurs, manifested by the familiar phenomena of
residual dilatation of the heart, mechanical congestion and dropsy,
a different set of measures are demanded. Now is the time to attend
with expedition, energy and completeness to the fulfilment of the
three great therapeutical indications for the treatment of cardiac
failure: to reduce the peripheral resistance; to increase the vigour
of ventricular contraction and rehabilitate hypertrophy; and to
remove arrears of work in the form of residual blood in the cardiac
chambers, mechanical congestion of the veins and viscera, and dropsy
of the integuments and serous sacs. Bodily rest; a light, solid
diet, and a definite allowance of alcohol, if required; active
purgation with mercurials, salines and jalap; and the exhibition of
sufficiently large doses of digitalis or one of its congeners, in
combination with saline and other diuretics--these are the means
calculated to attain the desired objects. You will not expect
me to enter into the many details of the management of cardiac
failure. It is not different in any important respect in the man
of middle or advanced age with cardiac degeneration from what it
is in an ordinary case of chronic valvular disease. Only on a few
points do I desire to dwell. First, that we must not be afraid to
purge these patients, if necessary, every morning. Secondly, that
when the appetite flags and flatulence occurs, instead of slops a
blue pill or a dose of calomel should be given, and light solids
persevered with. Third, that digitalis must be given freely, the
dose of the tincture, for instance, being raised to 15 or even 20
minims every four hours, if smaller doses, such as 7½ or 10
minims, fail. Unquestionably there is a disposition on the part of
some practitioners to pause or retrace their steps in the dosage of
this invaluable drug, alarmed by the irregularity, frequency and
smallness of the pulse. All these characters of the pulse call for
more digitalis, not for less. In this connection let me also say
that the most ready and accurate, because measurable, evidence of
the action of digitalis in cardiac failure is strangely disregarded
in ordinary practice--I mean the volume of the renal secretion.
We may be in difficulty, and we may differ with each other, as to
the tension of the patient's pulse and the use of continuing or
modifying the digitalis treatment, when all that we have to do is
to ascertain the exact degree of diuresis. Fourth, that nocturnal
restlessness and sleeplessness are to be met unhesitatingly with
permission to spend the night in an easy chair by the bedside.
Fifth, that, according to my experience, acupuncture and drainage
succeed perfectly in these senile cases with dropsy, as much as 10
pints or more of serum escaping in the course of 24 hours, to the
complete and often lasting relief of the circulation.
And now I must bring these lectures to a close. In doing so I feel
that I have not only to thank you, Sir, and the Fellows of the
Medical Society and our visitors for the favour with which I have
been received and the patience with which you have listened to
me, but at the same time to apologise for the many defects, both
in matter and in form, of what I have presented to you. It is a
fortunate circumstance for me that, whilst the subject was so large
and so difficult, the mode of treatment of it commonly associated
with the Lettsomian Lectures and your kind forbearance have enabled
me to conceal my shortcomings by free selection of less severely
scientific topics, and the employment of an easy style. At the same
time, may I claim a little of your favourable consideration for
the aspect in which I have regarded the disorders and diseases of
the heart and arteries in middle and advanced life? I should be
satisfied with the results of my efforts on this occasion, whatever
may be thought of their form, if I have succeeded in convincing you
of the practical advantage of regarding these complaints from the
side of their causes as well as of their pathological anatomy.
HARRISON AND SONS, Printers in Ordinary to His Majesty, St. Martin's
Lane.
INDEX.
Acute disease and cardio-vascular degeneration; 39
Alcohol and cardiac disease; 9, 18
Alcoholism, Heart in, Course of; 20
Alcoholism, Heart in, Pathology of; 3, 19, 20
Alcoholism, Heart in, Prognosis of; 36
Alcoholism, Heart in, Symptoms and signs of; 13
Alcoholism, Heart in, Treatment of; 42
Angina pectoris; 17, 21, 24
Angina pectoris, false; 35
Angina pectoris, Prognosis of; 40
Angina pectoris, Significance of; 35
Arteries, The, at 20 to 45; 3
Arteries, The, at 45 to 65; 3, 4
Arteries, The, at 65 to 75; 4
Arteries, Degeneration of, and Gout; 7
Arteries, Diseases of, after 40, causes of; 6
Arteries, Soundness of, after 40; 5
Atheroma and Gout; 7
Atheroma, Treatment of; 44
Beneke, Professor, on the normal Arteries after 40; 3
Beneke, Professor, on the normal Heart after 40; 3
Bright's disease and cardio-vascular disease; 11, 29
Bruit de galop; 35
Causes of cardio-vascular disease; 9
Coffee and cardiac disorders; 9
Compensation, Maintenance of; 44
Cycling and cardiac strain; 6
Diabetes and cardio-vascular disease; 10
Diagnosis, Differential, of cardio-vascular disease; 3
Emphysema and cardio-vascular disease; 11
Exercise, Abuse of, and cardio-vascular disease; 8, 26
Exercise, after 40, Uses of; 45
Failure of Heart, Treatment of; 48
Failure of Heart, with Digitalis; 49
Failure of Heart, with Drainage; 49
Failure of Heart, with Purgatives; 49
Faintness, significance of; 35
Fatty degeneration, Diagnosis of; 47
Fatty degeneration, Treatment of; 47
Fevers, Acute specific, and cardio-vascular disease; 11
Glycosuria and Heart Disease; 22
Glycosuria and Heart Disease, Prognosis of; 36
Glycosuria and Heart Disease, Symptoms and Signs of; 22
Golf and cardiac strain; 7
Gout and Atheroma; 7
Gout and cardiac strain; 7
Gout as a cause of cardio-vascular disease; 9
Gout and Heart Disease; 20
Gout and Heart Disease, Prognosis of; 36
Gout and Heart Disease, Symptoms and signs of; 20
Gout and Heart Disease, Treatment of; 42, 45
Gout, Irregular; 10
Gouty Heart; 20
Heart, The, at 20 to 45; 3
Heart, at 45 to 65; 4
Heart, at 65 to 75; 4
Heart of the business man; 12
Heart, Disorder of, after 40, Causes of; 6
Heart, Failure of, Treatment of; 48
Heart, Family; 14
Heart, normal, The, after 40; 3
Heart, Soldier's, The; 12
Heart, Strain of; 6
Heart, Strain of, after 40; 6
Heart, Strain of, in Gout; 7
High arterial tension from nervous strain; 8
Influenza and cardio-vascular disease; 11
Lead and cardiac disorder; 9
Metabolism, Disturbances of, and cardio-vascular disease; 9
Murmur, Aortic Diastolic, Significance of; 33
Murmur, Systolic Diastolic; 33
Murmur, Endocardial Diastolic; 33
Murmur, Mitral, Presystolic Diastolic; 33
Murmur, Mitral, Systolic; 33
Nauheim treatment; 45
Nervous influences a cause of cardio-vascular disease; 8
Nervous Strain and Heart Disease; 29
Nervous Strain and Heart Disease, Prevention of; 43
Nervous Strain and Heart Disease, Prognosis of; 39
Nervous Strain and Heart Disease, Symptoms and signs of; 29
Obesity and cardio-vascular disease; 10, 22
Obesity and Heart Disease, Symptoms and signs; 22
Old Age, Normal arteries in; 5
Old Age, heart in; 5
Operations in cardio-vascular degeneration; 39
Palpitation, Significance of; 35
Physical stress, a cause of cardio-vascular disease; 6
Prognosis, Elements of; 36, 40
Pseudo-angina pectoris; 35
Rowing and cardiac strain; 7
Running and cardiac strain; 7
Sound, First, reduplicated; 34
Sound, Second, accentuated; 34
Strain of Heart after 40, Prevention of; 45
Strain of Heart after 40, Prognosis of; 38
Strain of Heart after 40, Symptoms and signs of; 23
Strain of Heart after 40, Treatment of; 46
Strain of Heart before 40, Prognosis of; 38
Strain of Heart before 40, Symptoms and signs of; 25
Strain of Heart before 40, Treatment of; 45
Syphilis, a cause of cardio-vascular disease; 10
Syphilitic Heart Disease, Prognosis of; 37
Syphilitic Heart Disease, Symptoms and signs of; 28
Syphilitic Heart Disease, Treatment of; 44
Tea and cardiac disorder; 9
Tension, High, Significance of; 35
Tobacco Heart; 9, 15
Tobacco Heart, Prognosis of; 36
Tobacco Heart, Symptoms and signs of; 15
Tobacco Heart, Treatment of; 42
Treatment of cardiac disease, Preventive; 42
Treatment of cardiac disease, Principles of; 41