The Lettsomian Lectures on Diseases and Disorders of the Heart and Arteries in Middle and Advanced Life [1900-1901]

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.

I am on the point of passing from the subject of the nutrition of 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?

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.