# The Harveian Oration: Delivered Before the Royal College of Physicians on June 21, 1904/Prevention of Valvular Disease

II
A Suggestion in Regard to Preventive Treatment of Valvular Disease
I have referred to certain facts, mostly of recent discovery, bearing on the existence of our profession in the remote past and in reference to the partial knowledge to which the priests of I-em-hotep attained as to the circulation of the blood, a subject not without a certain interest, but the advances of that knowledge made subsequently, which have on more than one occasion been dealt with in this room, those now making, and those yet to be made in the future are of more practical importance to us.
The genius and the marvellous industry of Harvey first clearly unfolded the great secret of the course of the circulation, thus opening a wide door for the work of others, physiological and therapeutic. A recognition of the principles of blood pressure, and of the action of vasomotor nerves, and other advances have followed. We have attained to a larger, though I believe as yet only to a partial and provisional, hold of truth in these matters. As such we shall regard our knowledge if we are wise. The great mistake in all times has been that of believing that the truth already attained is the whole and that nothing remained behind.
​Our Egyptian and our Greek predecessors seem to have believed that they had attained to absolute and final knowledge on these subjects. While we smile at their error, let us be humble in estimating our own position and ever remember that we ourselves may be yet barely on the threshold.
Our father, Harvey, has exhorted us ever to search and to study out the secrets of nature by the way of experiment. Will you pardon me if I devote the remainder of this paper to an account of a humble attempt to carry out his mandate, if I narrate briefly an experiment dealing with a yet unsolved problem in the pathology of the circulation, to which I have devoted twenty-five years of my life?
I may plead the usage of speakers and writers who follow a tale or narrative by a moral or practical application, and perhaps I may also be allowed to say that the discovery that ancient Egyptian physicians advocated rest in certain forms of heart disease suggested to me the propriety of supporting this doctrine by a brief narration of my own experience in the same direction.
As the Egyptians were probably ignorant as to the action of the valves of the heart, they can only have known the fact that rest was beneficial, but not the reason.
​Valvular defect is one of the most important and perhaps the most common of circulatory diseases. It is one which probably we shall never be able to cure, and is thus likely to remain one of the opprobia of medicine. Is it possible to treat it by prevention? This is the problem upon which I wish to speak a few words. I am the more encouraged to do this because I know that various Fellows and Members of this College hold similar views to those which I desire to unfold.
Joints recover: Why does the Endocardium fail to do so?
There are in this audience many who have treated cases of acute rheumatism and cases of valvular disease in hundreds of instances. We are all aware that in acute rheumatism, however severe the joint lesion may be, however great the swelling, the pain, the local pyrexia, and the effusion, in the large majority of cases, after the usual treatment all these grave symptoms subside, or if they linger in any joint many of us know how certainly they will vanish if we stimulate the trophic and vasomotor nerves by small blisters applied to the adjacent skin, the final issue in most cases being the restoration of every joint to a normal condition. But, alas, we also know that when the endocardium covering the mitral or aortic valve cusps is in like manner attacked, a like restoration does not take place spontaneously ​excepting in few and rare instances. When regurgitation through the valve, shown by an apex bruit with accentuation of the second pulmonary sound, has occurred in acute rheumatism, if after treating the rheumatism we leave the affected heart to its own course, and the patient to his, persistent bruit, persistent pulmonary accentuation, hypertrophy, dilatation—in fact, life-long heart disease and its train of attendant evils follow in a large majority of cases, and mar or shorten life. Why should the rheumatic heart be so much more intractable than the rheumatic joint?
The Rheumatic Joint Rests, but not the Rheumatic Heart
No doubt the reason is that the joint can rest. The merciful influence of pain in the part affected insures repose for each affected joint. Suppose it were otherwise. Imagine pain absent and conceive for a moment that we could flex and extend an acutely rheumatic knee or elbow sixty or eighty times per minute continuously, what would be the fate of the joint? Is there any probability that restoration to the normal condition would follow? Few of us, I think, would expect it, for it is a physiological law that repair in a diseased organ cannot coincide with full functional activity. When the endocardium and valve cusps are inflamed pain does not give the signal for rest, for, indeed, pain or no pain, the toiling heart cannot intermit its labours.
Disastrous results of Valvulitis if not specially treated
During my thirty-five years of experience as a hospital physician and in private I have watched with special interest the fate of the numerous cases of endocarditis which came under my charge, endeavouring as far as possible to trace the later history of such cases for a lengthened period. During the earlier years I merely treated the rheumatism, believing, as I had been taught, that little or nothing could be done to prevent disaster to the heart. I had the pain of discovering that many, indeed most, of these cases merged into permanent valvular disease. This distressing experience induced me to experiment on various methods of preventive treatment. Of these, one has proved successful and has been constantly employed by me for twenty years.
The work of the Rheumatic Heart must for a time be minimised
The method is very simple; it is merely to give the heart the same advantages, the same opportunities for repair, so far as we can, that the joints enjoy; in other words, by every means in our power we lessen the work to be done by the heart. The most absolute quiet is enjoined, the patient lies with his head at a low level, pain and fever are subdued, no excitement is permitted, the patient is made as comfortable as we can make ​him, and sleep is encouraged—in fact, we seek to attain physiological rest. We follow the precept of our ancient Egyptian brother, declared so many thousand years ago: we give the ailing heart the nearest approach to rest that is practicable. In addition we administer sodium or potassium iodide, partly to help in the absorption of morbid exudations but chiefly to lower vascular tension, just as we give these drugs in cases of internal aneurism. Lastly, we endeavour to influence the cardiac vasomotor and trophic nerves reflexly by gentle and almost painless stimulation of those cutaneous nerves which we know from physiological data, and from the evidence of the referred pains of angina to be in close relation with the heart—viz., the first four dorsal nerves.
I believe, however, that by far the most important factor in the abortive treatment of endocarditis is rest, rest for many weeks, the slowing of the heart, the lengthening of the diastole, which is the only rest-time possible, the careful avoidance of high blood pressures, which the weakened and softened valve cusps cannot sustain without peril, and the diminution of the volume of the blood to be moved.
Only then, when functional activity is minimised, can we hope for repair of mischief, re-formation of destroyed endothelia and absorption of effusion in the valve cusps. Moreover, repair is only possible during the early stages of endocarditis; later the mischief is permanent, ​unalterable by any form of treatment. The method fails if from any reason it is found impracticable to slow down the heart, for example, if asthma, bronchitis, or pneumonia, or great nervous excitability co-exist.
I submit that these measures are rational, their objects being by affording rest to give opportunity for the exercise of the vis medicatrix naturae which is our sheet anchor, nay, indeed, to stimulate that natural reparative process which alone can effect restoration.
Two Objections to the Proposed Method
It may be objected that there are two difficulties in our path. First, in regard to diagnosis, how are we to distinguish the signs of commencing endocarditis from those of mere dilatation? In the great majority of instances in which marked and continuing bruit occurs, endocarditis is present and not mere dilatation, but I admit that in some cases discrimination is difficult. The wisest course is, if in doubt, to treat as endocarditis. Secondly, some physicians complain, as those at the Johns Hopkins Hospital have recently done, that they find difficulty in inducing private and hospital patients to submit to a sufficiently long period of rest. Occasionally that is so in the case of foolish or thoughtless persons, but in general, if the danger to which the heart is exposed be calmly and plainly stated ​to the patient, and also if the hope of perfect recovery be held out to him through the agency of prolonged rest, he will agree to give this method a fair trial. Such, at least, has been my experience.
Successful Results obtained
For twenty years continuously this method has been carried out. The results have been striking. The comparative absence of permanent heart disease after endocarditis has been in marked contrast to its frequency prior to the adoption of the treatment by rest. So striking indeed is the change that I confess it now seems to me that it would be an immoral act on my part to omit these measures in any recent case of endocardial disease.
If we make it a rule to watch carefully for incipient valvulitis and if, when we find it, we secure for the heart prolonged rest, I believe that it is in our power to diminish, in a most material degree, the frequency of chronic valvular disease of the heart.
PRINTED BY DONALD FRASER, 37 HANOVER STREET, LIVERPOOL