The LUMLEIAN LECTURES on the PRINCIPLES which GOVERN TREATMENT in DISEASES and DISORDERS of the HEART: Delivered before the Royal College of Physicians of London, March, 1898
Authors: R. D. Powell
Journal: BMJ (1898)

THE general line of treatment in the vast majority of cases of acute inflammatory diseases of the heart is the same.We might, after recognising the presence of heart disease, so far as treatment is concerned, keep our stethoscope in our pockets.For we have chiefly to consider the fundamental complaint of which,the cardiac affection is in most cases a part, and this disease is, in the majority of instances, acute rheumatism.Now, from the heart point of view, and indeed from any point of view, I think all authorities are now agreed that the right treatment of acute rheumatism is absolute rest in bed in woollen wrappings, a free relief of the bowels, and the administration of sodium salicylate in efficient doses, in combination with such alkaline remedies as the condition of the urine may suggest.It was shown very emphatically by the late Dr. Sibson' that the difference between absolute and incomplete rest in the treatment of acute rheumatism was an exemption from heart complication Of 7I per cent.as contrasted with 44per cent.We never see now those cases of acute rheumatism Involving three to six weeks' acute suffering so little influenced by treatment as to render possible the warm discussions of not thirty years ago at our clinical societies respecting the relative merits of alkaline drenches, multiple blisters, or mint water drinks and dry cotton wool applications in that disease.But few cases now endure more than five days' suffering under the salicylate treatment, and a treatment of the general disease thus successful can scarcely fail with due care and foresight to prove in some degree preventive of cardiac lesions,which are true manifestations of tbe rheumatic poison, usually of somewhat later appearacee, than the joint phenomena.The earlier statisitis, both with regard to the influence of salicylates and other drug treatments in lessening the ten- dency to heart disease in rheumatism, are for the most part valueless, being based on hospital cases, the previous exist- ence of heart affection not being certified, and the treatment before entering hospital not being given.It can scarcely be doubted, however, that the current view that salicylates do not lessen the liability to cardiac lesions is founded on the fallacy that cases early relieved of pain and fever by salicy- lates are often allowed to get up too soon.The so-called relapses are rightly described by Dr.Howard as rather "recrudescences of a disease not yet terminated."The average time spent in hospital for acute rheumatism-thirty days-is nearly the same under all treatments, the full alkaline treatment having a slight advantage; and during the greater part of this time the patient must remain in bed under strict treatment by warmth and rest and appropriate drugs.If, thlerefore, on the relief of pain and reduction of temperature the patient be regarded as convalesoent, and be allowed out of bed, he assumes the position of one with acute rheumatism still upon him treated with incomplete rest, and so becomes doubly liable to cardiac manifestations.I may pass by the local treatment of cardiac disease in rheumatism, with the remark that it varies according to the views of particular physicians.There is no doubt that a certain few cases are wisely treated variously at the physi- cian's discretion by cold or warmth, by blisters or leeches, according to particular indieations.It cannot be said that any one plan of treatment is to be recommended as superior inrallcases.Why should rest, absolute recumbency, be so important in acute heart affections?P We cannot still the heart but'we can lighten its burdens and lessen its restlessness.The mere difference between, lying down and standing.up-to the healthy heart is io beatsj a minute, or 6oo beats an hour.How much greater may it not be to the heart irritated by acute disease?The pulse naturally quickens as the temperature rises.Hence by mitigating pyrexia we, cmteria paribu, rest the heart.It is generally held by pathologists that pyrexia