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.
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.