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diff --git a/43780-0.txt b/43780-0.txt index efbf2b8..74e368d 100644 --- a/43780-0.txt +++ b/43780-0.txt @@ -1,36 +1,4 @@ -Project Gutenberg's The Lettsomian Lectures 1900-1901, by J. Mitchell Bruce - -This eBook is for the use of anyone anywhere at no cost and with -almost no restrictions whatsoever. You may copy it, give it away or -re-use it under the terms of the Project Gutenberg License included -with this eBook or online at www.gutenberg.org - - -Title: The Lettsomian Lectures 1900-1901 - DISEASES AND DISORDERS OF THE HEART AND ARTERIES IN MIDDLE - AND ADVANCED LIFE - -Author: J. 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You may copy it, give it away or -re-use it under the terms of the Project Gutenberg License included -with this eBook or online at www.gutenberg.org - - -Title: The Lettsomian Lectures 1900-1901 - DISEASES AND DISORDERS OF THE HEART AND ARTERIES IN MIDDLE - AND ADVANCED LIFE - -Author: J. Mitchell Bruce - -Release Date: September 21, 2013 [EBook #43780] - -Language: English - -Character set encoding: ISO-8859-1 - -*** START OF THIS PROJECT GUTENBERG EBOOK THE LETTSOMIAN LECTURES 1900-1901 *** - - - - -Produced by Ian Deane, Julia Neufeld and the Online -Distributed Proofreading Team at http://www.pgdp.net - - - - - - - -Transcriber's note: - -Text enclosed by underscores is in italics (_italics_). - -Small capital text has been replaced with all capitals. - -Minor typographical errors have been corrected without note. -Irregularities and inconsistencies in the text have been retained as -printed. - - * * * * * - - - - - HEART DISEASE - - IN - - MIDDLE AND ADVANCED AGE - - - - - The Lettsomian Lectures - - ON - - DISEASES AND DISORDERS - - OF THE - - HEART AND ARTERIES - - IN - - MIDDLE AND ADVANCED LIFE - - _Delivered before the Medical Society of London, Session 1900-1_ - - - BY - - J. MITCHELL BRUCE, M.A., LL.D., M.D., F.R.C.P., - - _Physician to Charing Cross Hospital; Consulting Physician to the - Hospital for Consumption and Diseases of the Chest, Brompton_ - - - LONDON: - HARRISON AND SONS, ST. MARTIN'S LANE - PRINTERS IN ORDINARY TO HIS MAJESTY - - 1902 - - - - - _To_ - - JOHN H. MORGAN, C.V.O., M.A. Oxon., F.R.C.S. Eng. - - _President of the Medical Society of London, 1900-1901 - - from his friend and colleague - - The Writer_ - - - - -CONTENTS - - - LECTURE I. - PAGE - - Introduction 1 - - Natural State of Heart and Arteries after 40 3 - - Causes of cardio-vascular disorder and disease 6 - - Physical Stress 6 - - Nervous Influences 8 - - Cardiac Poisons 9 - - Disturbances of Metabolism 9 - - Gout 9 - - Syphilis 10 - - Acute specific fevers 11 - - Chronic affections 11 - - Complex causes 11 - - Old-standing Rheumatic Lesions 13 - - Family heart 14 - - - LECTURE II. - - Clinical Characters and Course 14 - - Clinical Characters and Course of Tobacco Heart 15 - - Clinical Characters and Course of the Heart in Alcoholism 18 - - Clinical Characters and Course of the Heart in Gout 20 - - Clinical Characters and Course of the Heart in Obesity - and Glycosuria 22 - - Clinical Characters and Course of Cardiac Strain 23 - - Clinical Characters and Course of Cardiac Strain before 40 25 - - Clinical Characters and Course of Syphilis of the Heart 28 - - Clinical Characters and Course of cardio-vascular disease - from Nervous Strain 29 - - - LECTURE III. - - Diagnosis, Prognosis and Treatment 30 - - Differential Diagnosis 31 - - Value diagnostically of different physical signs 33 - - Value diagnostically of different symptoms 35 - - Prognosis 36 - - Treatment 37 - - Conclusion 50 - - - - -THE LETTSOMIAN LECTURES - -1900-1901 - - - - -LECTURE I. - - -MR. PRESIDENT AND GENTLEMEN,--My first duty this evening is to -thank you, which I do most heartily and gratefully, for the -honour you have done me by selecting me to deliver the Lettsomian -Lectures for the present year. My second duty is to spend as little -time as possible on preliminary remarks, for--as you, Sir, know, -having yourself occupied this distinguished place on a former -occasion--three hours are all too brief for useful presentation of -material which one has collected for a purpose like the present. In -selecting the subject of my Lectures I was mindful of the character -and objects of this Society. In the Medical Society of London there -is a fuller blending of men engaged in family practice with men -holding hospital appointments than is the case at most of the other -learned societies connected with our profession in London; and -there is here an opportunity for free communication of experience -and interchange of opinion between these two classes of our Fellows -which cannot fail to be profitable to both. Therefore, I have taken -up a subject of thoroughly practical interest; and not only this, -but I will attempt to present it to you, to put you in a position -to look at it, from the point of view of the practitioner. The -problem of the diseases and disorders of the heart and arteries -in middle and advanced life may be said to come before the family -practitioner every hour of his work, and to offer difficulties and -create a sense of responsibility or even anxiety which are not -sufficiently appreciated by the hospital physician. There comes -before him the case of one of his patients, an active business -man of 45, who has been seized with angina pectoris when hurrying -to the station after breakfast, or that of an old friend, whose -proposal for an increase of his insurance at 50 has been declined -because of arterial degeneration and polyuria; or he is asked to -say whether a man of 60, occupying an important and possibly -distinguished position in the community, ought to retire from public -life because he has occasional attacks of præcordial oppression -and a systolic murmur at the base of his heart. What, again, is he -to do for the stout, free-living man, just passing the meridian of -life, who consults him for weakness and depression, whose heart is -large and feeble, and the urine saccharine and slightly albuminous? -There is not one of my audience who has not met with such cases as -these many times in his practice, and a variety of other cases of -cardiac disorder and disease after 40, where the importance of the -individuals, the value of their lives, and the gravity of their -complaints and their prospects have exercised him very anxiously. -What is the prognosis in cases of this order? What can be done for -them in the way of treatment? These are the questions which we -would desire to answer usefully. The answer, it seems to me, can be -given only after an analysis and study of a considerable number of -instances of the kind, in respect of their origin, their clinical -characters and course, and the result. This is the method of inquiry -which I propose to follow. It will be a study of cardio-vascular -disease in older subjects from the clinical point of view, and it -will be approached not only from the ordinary clinical side as -it is approached in hospitals, that is, by an investigation of -symptoms and signs, but also and especially in the light of that -particular order of knowledge which the family practitioner has -learned to appreciate and has so intimate an opportunity to acquire -correctly--a knowledge of the origin or causes of the different -affections, which it is always difficult, and often impossible, for -the hospital physician to ascertain. For the same reason, although, -to be complete, a study of the diseases of the circulation at and -after middle life should include an account of the _post-mortem_ -characters found in fatal cases, and whilst the basis of the -account I submit to you will be essentially pathological, I shall -not attempt to describe the pathological anatomy and histology of -this group of lesions of the heart and arteries. This part of the -subject has been remarkably advanced during the last few years; -and even if I had the time and the necessary knowledge to deal -with it now, I should have nothing original in it to lay before -you. Indeed, if I may venture to say so, our attention lately has -been too much confined to the pathological states of the heart and -arteries and too little directed to the causes which produce them. -"Arterial sclerosis" is now an ordinary diagnosis in every-day -practice, as if it were sufficient for purposes of prognosis and -treatment to have determined that the radial artery is thicker and -longer and more dense than normal, without regard to the actual -nature of the pathological change, whether strain, or syphilitic, -or gouty, or otherwise. And in the same way the phrase "dilatation -of the heart" is now in everybody's mouth, irrespective of -considerations of its origin. Not only has the profession suddenly -woke up to the recognition of a form of enlargement of the heart -which was fully described fifty years ago by physicians in our own -country, but the public have made "dilated heart" a fashionable -disease which calls for the advice of a specialist and an annual -visit to a Continental spa. We ought to have advanced beyond this -stage of cardiac pathology long before this time. Besides, of how -much greater interest is it in our every-day work to study the -causes or circumstances that lead up to disease than the simple -state of disease itself! And there is in a study of this kind -an opportunity afforded to the family practitioner of advancing -Medicine--scientific, preventive and therapeutical--as surely as if -he were a pathologist in the _post-mortem_ room or laboratory. - -Before, however, examining the influences and circumstances which -disorder and damage the circulation in middle and advanced life, let -us see what the normal or natural state of the heart and arteries -is after 40. It has been ascertained that the different parts of -the circulatory apparatus pass through certain definite phases -of change in the different stages of that decline of existence -and energy which leads to senility and ends in death. We have to -thank Professor Beneke, of Marburg, for the results of a laborious -investigation of this subject which are generally accepted and which -I will attempt to summarise.[1] - - [1] F. W. Beneke, 'Die Altersdisposition.' - -We should all expect the cardio-vascular system to undergo important -changes with increasing age; but few of us would be prepared to -find that these changes are neither uniformly progressive nor -indeed continuously progressive in the same direction. To make -more easily intelligible the nature and as far as possible the -origin of these anatomical alterations in the heart and arteries -during the second half of life, I will first refer for a moment -to the circulation from 20 to 45. During this period of life the -blood-pressure is relatively high, reaching its maximum about 36; -the aorta and other large arteries increase in diameter from the -stress of the blood-pressure on their elastic walls, particularly -between 35 and 45, and the heart increases in size year after year -at a nearly uniform rate. We have in these facts anatomical evidence -of the great functional vigour and activity of the circulation in -manhood. At 45, which is practically the commencement of the period -with which we are concerned, remarkable changes occur. Whilst the -arteries continue to increase in circumference (somewhat more slowly -than before), the blood-pressure falls and the heart begins--almost -suddenly--to diminish in size; and these three features characterise -the circulation for the next 20 years, that is, until the age of -65. How is this fall in the size of the heart to be accounted for? -Partly by the widening of the arterial trunks and the consequent -fall of pressure. But not by these only; for although the arteries -had been widening even more rapidly between 20 and 45, the pressure -was actually at its maximum then and the heart large, and we shall -presently find other facts opposed to this view. The peripheral -resistance in the systemic arteries must fall from some other cause -or causes in middle age than the loss of elasticity of the arterial -walls, and these causes are probably reduction of mechanical stress, -due to comparative bodily relaxation, loss of vaso-motor tone in the -splanchnic area, and the chronic diseases of which the subjects have -died whose hearts and vessels are measured _post mortem_. During -this phase of life also, the blood becomes more venous in quality -and its hæmoglobin value is lowered. - -At 65, other changes which occur in the heart and arteries are -not less striking than those which I have just described. The -decline of circulatory energy, and the effects of time itself -on the protoplasm of the cells of the body, have so lowered the -metabolic and functional energy of the tissues and organs and the -activity of the blood-supply, that a considerable proportion of the -capillary network becomes obsolete. The peripheral resistance is -thus increased, and the blood-pressure rises; therefore the heart -once more increases so much in size that at the end of the 10 years -(age 75) it is found as large as it was at 45, and at the same -time the hæmoglobin value of the blood again proves to be higher. -During this period, also, the arteries continue to grow wider and -thicker and longer--another proof that the size of the heart is -not determined solely by their calibre. Regarded as a whole, the -process of senescence of the cardio-vascular system presents to us a -beautiful instance of anatomical readjustment and compensation--the -counterpart, in a way, of the growth of the circulation in energy -and activity during the period of full manhood. The arterial walls, -which have been stretched in their diameter and in their length by -exhaustion of their elasticity under the stress of cardiac systole, -are strengthened afresh by the development of stays formed of -fibroid and muscular tissues in the intima and media; and the heart -responds to the altered mechanical condition ahead of it in the -arteries, and to the increased peripheral resistance caused by the -obsolescence of many capillaries, by growing afresh. - -This account relates to the size of the arteries after 40; now let -us inquire what is the condition of their structural elements. The -changes described do not necessarily involve disease of the tissue -elements, unless we were to call every senile change morbid. My -friends Dr. Bosanquet and Dr. Mullings have given me an account of -the state of the heart and aorta in the bodies of 25 men, aged 40 -and upwards, examined in the _post-mortem_ room of Charing Cross -Hospital, who had died from accident or suicide. The average age -was 53½ years, and the aorta presented some degree of atheroma -in half the cases. When we consider how very slight a change in the -arch of the aorta is habitually described as "atheroma," and that in -a few of the cases the valves were diseased and the heart enlarged, -we are justified in concluding that in the majority of persons of -53 the arteries are still sound. This result is in accord with that -obtained by the late Professor Humphry, who devoted his attention so -long and so successfully to the investigation of old age. He states -that in the great majority of cases the arterial system appears to -present a healthy condition in those who attain to great age.[2] -Even among the majority of centenarians the evidences of arterial -degeneration were not manifest.[3] And we know that we occasionally -meet with people of 80 and upwards whose pulses are unexceptionable, -beyond presenting a trace of thickening and enlargement. - - [2] Humphry, 'Old Age,' 1889, p. 23. - - [3] _Op. cit._, p. 48. - -For my present purpose, therefore, we may conclude that as age -advances, the arteries naturally become wider, longer and thicker, -and altogether larger than in early life; and that we must not -speak of "vascular degeneration" in an evil sense as often as we -find these conditions present. As for the heart, we know that it -may remain structurally sound, and is more often regular than -irregular, to the most advanced years of life. Conversely, these -facts suggest that actual diseases of the arteries and heart, that -is, other than the changes which are found in all persons after 45, -are not properly senile in their nature. As Professor Humphry said, -they are no part of, but are rather to be regarded as deviations -from, or morbid departures from, the natural phenomena.[4] They -must be the effects of pathological processes due to a variety of -pathogenetic influences which assail the circulation. Now we are in -a position to study these. - - [4] Humphry, 'Old Age,' 1889, p. 15. - -After the age of 40, many of the influences that threaten the heart -and arteries with disorder and disease are peculiar to this period -of life--that is, different and distinct from the causes of cardiac -and vascular affections in childhood, adolescence and manhood; -others of them have been encountered already, with or without -permanent damage as the result. I will now examine them in detail, -and at the same time refer to certain provisions with which the -heart and arteries are endowed for resisting them and recovering -naturally from their effects, as well as to the circumstances -which render these provisions abortive or insufficient, and thus -predispose to disease or indirectly determine its occurrence. - - * * * * * - -1. _Physical stress_ is still a definite cause of cardiac and -vascular damage during the second half of life, in the forms both -of sudden violent exertion and of ordinary laborious occupations. -I have met with instances of acute and serious strain at all ages -over 40, up to and even after 70. I am aware that I must speak on -this part of my subject--the evil effects of muscular exercise--with -great caution in the presence of you, Sir, our President, who -have long been recognised as one of the principal patrons in our -profession of athletic sports, and so highly distinguished yourself -in them at Oxford and in the inter-University contests. I assume -that you are unwilling to admit that muscular exercise is dangerous -to health. But I feel sure that you will agree with me that when the -man of 65 rushes from his breakfast-table to catch his train, or -the lady of 70 hurries up a hill in Wales to be in time for morning -service, or the middle-aged father on holiday, who has just started -a bicycle in order to reduce his weight, takes the pace from his son -of 17, the effect on the heart and arteries is likely to be serious. -I have notes of a good many cases of cardiac strain in middle-aged -and old persons from cycling; a very few from violent efforts -to drive at golf; a few from efforts at lifting or resisting -heavy weights; and one notable case in which a member of our own -profession, a man of 45, belonging to the Royal Army Medical Corps, -broke down with acute cardiac dilatation during General French's -memorable ride to relieve Kimberley. In some of my cases there was -no reason to believe that the heart was other than sound before the -strain; but in a majority of them (and I have analysed 40, of which -I have more or less full notes) one or more of the safeguards of -the circulation against strain were already defective or wanting. -What are these? In the heart, chiefly a high degree of extensibility -or elasticity of its tissues, permitting over-distension of the -chambers, with safety-valve action of the tricuspid in extreme -cases, and a sound and vigorous musculature to effect the increased -action, and if necessary the hypertrophy, which mechanical stress -demands--in a word, healthy, well-nourished cardiac walls. It is -an interesting fact that two-thirds of my cases of cardiac strain -in the second half of life presented also a history of gout, fully -developed or irregular--in other words, a history of perverted -metabolism. Equally striking is another fact in this connection: -that in many cases the occurrence of strain in middle or advanced -age was but the latest of a series of similar events as the result -of muscular effort for a period of 10, 20, 30, 40, or even 50 -years--in other words, the heart had been strained originally in -youth or early manhood, and had given serious trouble as often as -it was taxed again. Rowing or running at college was in a good many -instances given as the cause of the first strain. I need not do more -than mention previous valvular disease, usually of rheumatic origin, -as a condition powerfully predisposing to cardiac injury by physical -exertion. Excepting in this indirect way, rheumatism has no effect -in lowering the resistance of heart or vessels to mechanical stress. - -The principal safeguard which the arteries possess against strain -is, of course, the extensibility and elasticity of their tissues. -Unfortunately the metabolic disorders, including gout, which we have -just found weakening the cardiac walls, are amongst the commonest -causes of arterial degeneration also; and the two influences--gout -and strain--acting together no doubt are accountable for a -considerable number of cases of atheroma and chronic arteritis. It -naturally might occur to us that gout and exertion could not well -be associated, but this very consideration serves to explain their -mutual influence in straining the heart. It is unwise, ill-timed, -ill-planned muscular exercise that injures the circulation, most -often on the part of the middle-aged man, who, awaking to the -consciousness of growing fat and gouty, rushes inconsiderately to -violent exercise for relief. - -2. It is generally recognised that nervous excitement and other -_nervous influences_ tax the circulation; and endless phrases -and expressions, articulate and inarticulate, testify to the -universal belief in the close connection between the heart and the -emotions. Quite recently Dr. Leonard Hill and Dr. George Oliver -have demonstrated instrumentally the rise of blood-pressure that -accompanies cerebral activity.[5] No doubt many cases of disorder -and disease of the walls of the heart and arteries originate in -distress, worry, anxiety and protracted suspense; and the connection -is most often seen in middle and advanced life, because these -depressing emotions fall most heavily upon mankind at this period. -Of the instances which I have met with I will mention but one or -two by way of illustration. A member of the Reform Committee at -Johannesburg at the time of the Jameson Raid, who had been confined -in Pretoria Jail, came home sometime afterwards with the ordinary -symptoms and signs of fatty degeneration of the heart, and died -suddenly on the street. A detective officer who had tracked suspects -and criminals all over the world, facing great personal danger, -and on one occasion had to convey a parcel of dynamite found -near a Government office to a place of safety many miles away, -came under my care later on with arterial sclerosis and cerebral -thrombosis, for which no other cause but a life of adventure could -be discovered. These were cases of actual disease of the heart and -arterial system respectively; and I need not add that disturbances -or disorders of the circulation, of every degree and variety, the -result of nervous excitement or depression, come constantly under -our observation, especially in women. I would particularly mention, -however, a group of cardio-vascular troubles that lie between these -two extremes. I have frequently observed that persons of anxious -and energetic temperament, burthened with responsible work of a -heavy, constant and prolonged character, when they break down, -as they often do, present the clinical features of high tension: -the pulse is full, the heart is large, the second aortic sound is -loud and ringing; there is polyuria, and a trace of albumen may be -found. This disturbance of the circulation, strongly suggestive of -contracted kidney, is as common in women as in men--for instance, -in matrons of schools or hospitals. Nevertheless, however clear -the direct connection between nervous strain and cardio-vascular -disease may be in many instances, it is in other instances unreal, -or more correctly indirect only. This is a matter of great practical -importance. First, the nervous temperament often drives the subjects -of it to physical overwork in the form of incessant and prolonged -devotion to work, with insufficient hours of rest and sleep, and to -unwise attempts to remove nervous exhaustion by violent muscular -exercise, as we have just seen. In the second place, alcohol -undoubtedly plays an important part in many instances regarded -as overwork and worry and nervous exhaustion, both in men and in -women--alcohol taken to enable more work to be accomplished, to -steady the nerves, to promote sleep, to drive away care, or to -relieve the faintness which it has itself induced. And thirdly, -many of the complaints of nervous depression, lowness and worry are -really due to gout, to influenza, and the like, which are at the -same time the true causes of the cardiac symptoms. - - [5] Leonard Hill, Allbutt's 'System of Me inc,' vol. xii; George - Oliver, 'The Blood and Blood-Pressure,' p. 170, 1901. - -3. What I have just said in connection with nervous causes of -cardio-vascular affections brings us naturally to that important -group of agents which may be summarily called _extrinsic cardiac -poisons_--alcohol, tobacco, tea, coffee and lead. I will not -dwell on this subject at present, for there is no need to prove -the reality of the connection, and I shall have occasion to refer -to some of these poisons at greater length under the head of -diagnosis. Alcoholic heart occurs both in men and women; tobacco -heart is extraordinarily common in our own profession, and common -in clergymen and in retired members of the public services; tea-, -coffee-, and cocoa- poisoning I have met with principally in -students. - -4. There can be no question but that by far the most prolific causes -of cardio-vascular disorder and disease after 40 are _disturbances -of metabolism_, including gout--at any rate amongst the middle -and upper classes in this country. This period of life brings -with it in many instances comparative relaxation from work, and a -disposition to substitute quiet or even passive for active exercise; -and whilst the demands of growth and development on the alimentary -system have greatly declined, the pleasures of the table and ease -generally are too often indulged in as a privilege of advancing -years and the legitimate reward of previous years of work. The -results are functional disorders of the liver, gout in regular and -irregular forms, gravel, and the many associated disorders of the -muscular, nervous and other systems. At the same time the arterial -tension rises, for the body possesses a physiological provision for -eliminating the nitrogenous products of metabolism, whether normal -or abnormal, namely, the kidneys, the vaso-motor mechanism and the -heart. Stimulation of the vaso-motor centre by nitrogenous waste -raises the arterial pressure; the heart is excited to more vigorous -contraction (if necessary it hypertrophies); and the consequent -polyuria washes the intrinsic poisons out of the system. Thus it -happens that in metabolic disorders, from excessive or unwholesome -eating and drinking, the heart, vessels and kidneys are kept under -incessant strain; and, like other organs working under strain in the -gouty subject, they are the readiest to suffer--first from disorders -of many kinds, and ultimately, unless reform be enforced, from -cardio-vascular degeneration and chronic Bright's disease. - -Of the many cases of this kind that I have seen at all ages between -40 and 80 (and others before 40), the proportion of irregular gout -to acute articular gout was about 3 to 2. Under irregular gout -I include goutiness in its many forms--sick headache, eczema, -sciatica, lumbago, acid dyspepsia, irritable bladder, asthma, -insomnia, vertigo, depression, and the familiar complexion and -appearance generally of "the gouty individual," all variously -combined. - -In other cases the metabolic disturbances come before us not as -gout or even goutiness in the ordinary acceptation of the term, -but in the forms of obesity, of diabetes, of gravel, of irregular -albuminuria, and of the effects of large eating and free living in -general. - -5. _Syphilis_--that fruitful cause of vascular disease, and both -directly and indirectly of cardiac disease--has by no means ceased -to attack the organs of circulation after 40. Whatever the date of -the primary infection, syphilis is a standing danger to the heart -and arteries in the middle-aged man and even in declining years. -Thus, in 11 cases belonging to this group, the average age at which -they came under my observation (most of them but not all complaining -of cardiac distress) was 55. All of these were men. I ought to add -that in a considerable proportion of the cases either physical -strain, alcohol, tobacco or Bright's disease was associated with -syphilis in the etiology, and sometimes more than one of these. - -6. For the man and woman of forty years of age and upwards, most -of _the acute specific fevers_ are affairs of the past. But the -liability to several of them remains, and, very unfortunately, the -liability to those acute specific processes which may attack the -cardio-vascular system--influenza in particular, and less often -typhoid fever, rheumatism, diphtheria and pneumonia, as well as -septicæmia of different forms or kinds, which works havoc throughout -the entire circulation. I should have had more to say under this -head but for the fact that our distinguished Fellow and former -President, Dr. Sansom, has thoroughly investigated it, and on more -than one occasion laid the results before you. - -7. I will not occupy your time this evening in tracing the -origin of certain cases of cardio-vascular disease in middle and -advanced life to _chronic affections_ of different kinds. Besides -the obvious effects upon the heart, blood and blood-vessels, of -anæmia, exhaustion, &c., we meet with such grave lesions as fatty -degeneration from pernicious anæmia and other blood disorders; -profound circulatory derangements and occasionally valvular lesions -in Graves's disease, and others. - -8. I now pass on to _complex causes_. In addition to the definite -and distinct influences which I have mentioned as threatening the -heart in this stage of life, there are two which are intimately -associated with other causes of cardio-vascular disease, but still -deserve to stand out independently. The first of these is emphysema, -and along with it other chronic affections of the lungs and pleura, -which strain the right ventricle; the second is chronic Bright's -disease, which similarly strains the left ventricle. I shall have -frequent occasion to return to these two morbid states in different -parts of my subject. I mention them here to give them the position -which they deserve as influences that threaten the function and -still more the structure of the heart and arteries. They are often -associated with each other, and each or both of them with one -or more of the unfavourable influences I have just enumerated, -particularly alcohol, disordered metabolism and gout. And this -brings me to the many instances in which the different influences -that threaten the circulatory organs in middle and advanced life act -together in different combinations. Alcoholism is equally common -amongst the poor, whose circulation is subjected to mechanical -stress, whilst it is impoverished by want; the well-to-do, who lead -luxurious, sedentary enervating lives; and, as I have already -observed, the keen active business or professional man who overworks -his brain on stimulants. In this country at least, gout appears to -be all-pervading, and as an unfavourable influence on heart and -vessels it often cannot be dissociated from alcohol, sedentary -habits, worry, plumbism, Bright's disease and emphysema. - -Thus, in our study of combinations of morbific influences we come -to appreciate the evil effect of certain _occupations_ upon the -circulation in middle life. The business man is exposed to the -unhealthy actions on his heart of confinement to a close office -or shop, worry, irregular hasty feeding, alcoholic indulgence in -connection with his trade or profession, and unwise attempts at -violent muscular exercise at the week-end or in the holiday season; -or he may be guilty of entire disregard of the rules of bodily and -mental hygiene, and bring on in this way premature degeneration of -his cardio-vascular system. Still more numerous are the causes at -work in the production of "soldier's heart." We have but to picture -to ourselves, if we can, the physical strain, the mental excitement, -the bodily hardships--including exposure to both extremes of -temperature--and the coarse fare which have been the lot of many -thousands of our brave troops in the Boer war, to understand how the -fighting soldier "ages" quickly, and, in particular, ages in his -heart and arteries. Add to these unfavourable influences syphilis, -alcohol and tobacco (which, unfortunately, must be added in many -instances), and the chance of escape from disease of the circulation -in the soldier is practically _nil_. But "soldier's heart" is also -met with elsewhere than in the army. The clergyman from the slums -of London or other great city, who has lived and toiled and--it may -be said truly--has fought with various success through alternate -periods of excitement and depression, and has thus suffered much -both in mind and body, comes to us with high-tension pulse, a -tortuous radial artery, a large heart and a systolic murmur over -the aorta, and complains of an attack of angina. His wife, who has -laboured in the parish for years (she is 76, and still active in her -work of charity), has also a thickened radial artery, a large heart, -and a systolic basic murmur, with no discoverable cause of these -evidences of a diseased circulation but the life that she has led -amongst the poor around her. Perhaps such cases of cardio-vascular -disease might be most correctly said to be due to the wear and tear -of life. They are met with also in the traveller or explorer, who -has spent most of his life in search of adventure; and they are -found in a man who has never left home, but whose years have been -filled with the toil and anxiety of his position as an owner of -land, or with prolonged litigation. - - * * * * * - -Such are the principal natural influences which individually or -in different combinations threaten or assail the sound heart and -blood vessels after the age of 40. I have given but a broad, hasty -sketch of them entirely from my own recent observations, and I -know that I have omitted some which in your opinion might deserve -mention, but which possess no special interest in relation to this -period of life--for example, the agents of acute infections of -the endocardium, and also new growths, pregnancy and parturition. -Let me now sum up the results, and say that whatever changes the -cardio-vascular system may present in middle and advanced life, -beyond those which we have found to be natural to it at those -particular periods, are pathological--the result of physical stress, -nervous influences, extrinsic poisons, disturbances of metabolism, -syphilis, acute disease, or chronic disease; or are associated -with chronic nephritis, emphysema or different combinations of the -preceding causes, with various occupations or positions in life, or -with other influences of less importance. It is necessary, however, -to qualify this statement in two respects. In the first place, the -heart and vessels may have been so damaged already, that is, in -early life, that they fall victims to influences which, whether -in kind or in degree, would have been insufficient to produce -idiopathic disease of these organs. This brings me to the subject of -old-standing valvular disease (mostly rheumatic in origin), chronic -strain, and adherent pericardium in middle-aged and old subjects. -A considerable proportion of our cases are of this type, and they -have to be mentioned here for the sake of giving completeness to -the plan of arrangement, but they are outside the range of our -immediate subject. In the second place, hearts and arteries at 40 -that appear to the naked eye free from damage may be molecularly -weak, and unable to offer effective resistance even to influences -of an every-day character. I have now arrived at the last, and -certainly one of the most interesting, of the causes of disease of -the heart and arteries in middle and advanced life. There are some -persons whose hearts and arteries cannot carry them through the wear -and tear of what may be called ordinary life for more than 40 or 50 -years. The vital energy of the tissues of these organs is exhausted -prematurely; they are already old at 45; degeneration of the -muscle and other cells sets in early, reminding us of the essential -myopathic paralysis of children. This type of case is described as -"family heart," for it also runs in families--three, four, five, -or more members of which, as in a number of instances that I have -observed, may have all died suddenly of cardiac disease--some of -them at an early age. Similarly, it is not by any means unusual to -find quite young subjects, say of 30, with vessels already much -enlarged; and I may add, equally young subjects with their lungs -already emphysematous although there is no history of respiratory -strain, reminding us of the very common association of emphysema -with arterial sclerosis in old age. These cases of family heart and -premature arterial sclerosis are the links that connect disease of -the heart and arteries in middle and advanced life of definitely -pathological origin with the genuinely senile changes in the -tissue-elements which render existence untenable at last, and which -may be said to be the result of the exhaustion of their nutritional -activity by "the thousand natural shocks that flesh is heir to." - - - - -LECTURE II. - - -MR. PRESIDENT AND GENTLEMEN,--In my last lecture I presented to -you a brief account of the condition of the organs of circulation -between the ages of 40 and 75, and I then proceeded to direct your -attention to the principal influences which may disorder and damage -them during that period of life. I will now attempt to describe -the clinical characters and course of the affections of the heart -and arteries, as I have observed them, in connection with these -different influences respectively--whether gout, mechanical stress, -syphilis, or other. Thereafter, if time permits, I may be able to -examine the different symptoms and signs individually in order to -discover the value of each as a guide in diagnosis. - -Now, as I have already pointed out, the causes of cardio-vascular -disease in the second half of life are very often, indeed usually, -complex. It follows, therefore, that if we desire, as we do most -particularly, to discover the effects of each pathogenetic influence -as distinguished from the others, we must begin our study with the -simplest, or purest, or most definite of all, and proceed from it -towards those which are more difficult, as well as to combinations -of causes. It is easy to adopt this method in our present inquiry. - - -TOBACCO HEART. - -We have in tobacco a single distinct influence at work; one that is -universally acknowledged to affect the heart and vessels, and the -physiological action of which is understood; one, further, that can -be removed (perhaps not without some difficulty, for I have had a -patient plead for his pipe with tears in his eyes), and certainly -that can always be resumed with remarkable readiness--in a word, -a most favourable subject of observation by experiment. It is -well, too, to begin the study of tobacco heart in young men, whose -circulation is still structurally sound, and thereafter to follow -up the subject in middle-aged and old persons. Adopting this line -of inquiry, I have found that the uncomplicated effects of tobacco -on young healthy hearts, as they present themselves clinically, -are: palpitation in every instance; a sense of irregular action,[6] -post-sternal oppression and pain in half the cases; and in one out -of every eight sufferers either angina or uncomfortable sensations -in the left arm. Faintness or actual faints occurred in one-third, -and giddiness and a feeling of impending death in a smaller -proportion. Turning to the physical signs, the heart proves to be of -ordinary size in 50 per cent. of the patients; in a few it is very -slightly enlarged; the præcordial impulse is often very weak, but -occasionally increased in force and frequency, and almost as often -irregular as not; the pulse tension, with insignificant exceptions, -I have always found low. Very interesting, in the light of what I -shall tell you later on, is the fact that of 20 of these patients -complaining of the heart not one presented a cardiac murmur beyond a -weak mitral systolic bruit, varying with posture or cubitus. This is -in accordance with the teachings of pharmacology --that tobacco acts -on the terminal branches of the vagus. - - [6] A medical friend who has suffered from tobacco heart assures - me that at one period he could distinguish the contractions of the - auricles and ventricles. - -Now we are in a position to study the tobacco heart in a man of 40; -and again let us begin with a man who is sound, active, and healthy -otherwise. He complains of his heart, and recognises willingly -(for he belongs to our own profession), in the discomfort and -anxiety from which he suffers, the penalty of having smoked for -years the strongest and blackest tobacco that he could buy. Yet his -heart is not enlarged, and the cardiac sounds might be described -as ordinary were they not peculiarly irregular, the frequency -changing every moment and a falter occurring at short intervals. -There is not a trace of murmur to be found in connection with -the valves and orifices. At ages over 40 a clinical study of the -tobacco heart is highly instructive from a practical point of view. -Whilst palpitation is still the common complaint, pain, including -angina, is put forward more prominently, and so are faintness, -actual faints, a feeling of impending death, and a sense of cardiac -irregularity, each intermission being accompanied with a sudden -stab through the præcordia. Some of you will remember Mr. Barrie's -quaint account in 'My Lady Nicotine' of what he calls the horrors -of his smoking days, when the pain at his heart made him hold his -breath--"a sting" as he describes it, and he believed he was dying. -In these subjects the heart is more frequently found to be large and -feeble; the same weak systolic murmur is occasionally to be heard; -the radial pulse is often irregular, and the vessel wall naturally -thick. This, you will notice, is a combination of symptoms and signs -sufficient to alarm the casual observer. But when we examine it more -deliberately, in the light of our study of the tobacco heart in -young subjects, on the one hand, and of our knowledge of the normal -or natural condition of the heart and arteries at 60, on the other -hand, we are able to reassure ourselves and our patients. We are -justified in concluding not only that every cardio-vascular lesion -which may be found in tobacco smokers is not to be put to the credit -of tobacco, but, _vice versâ_ (and this is of more interest to us in -our present inquiry), that every præcordial pain, angina, faintness, -or irregular pulse in a man of 60 with a full-sized heart is not to -be hastily regarded as evidences of grave disease without further -inquiry as to his habits. The cardiac enlargement and large pulse -may be nothing more than the result of a life of bodily and mental -activity: the præcordial distress may be the result only of tobacco. -How very necessary this caution is will be impressed upon your -consideration by the two following cases. The first is that of a man -of 60, actively engaged in professional pursuits, who first suffered -from præcordial pain of an alarming character four and a half years -ago, and has had attacks since, particularly during exertion and -after meals. One day last autumn, at the end of many hours' hard -work, cheered by at least 18 cigarettes, he was rushing off to dine -with a friend when he was suddenly seized with præcordial pain which -he described as fearful, radiating down the left arm. He broke into -a cold sweat, thought that his last hour had come, and for a short -time had impairment of consciousness. Shortly after this event he -took the advice of his doctors and gave up tobacco (shall I say for -a time?), and from that day to this, now six months, he has had no -further trouble with his heart. - -The second case is equally striking. A man of 55, of fairly active -disposition and somewhat full habit of body, was suddenly seized -with angina pectoris in October, 1899. The pain was of a dull -bursting character over the region of the heart, and it passed into -the left shoulder, down to the elbow, and settled particularly in -the wrist. At the same time there was pain in the upper maxillary -region. The heart slowed down from 75 to 50, and the sufferer felt -that he was dying. From that time anginal attacks occurred in -rapid succession, five, six, nine or even eleven in a single day; -occasionally they came on in the night. This experience continued -for nearly two months on end; indeed, it was six months before the -angina finally ceased. It was instantly relieved with amyl nitrite; -nitro-glycerin was unsuccessful. In the course of giving advice to -this patient I fortunately discovered that he had just laid in a -stock of 2,000 cigars. The line of treatment was obvious; and the -result has been, as I have said, complete recovery. - -I have dwelt on the subject of tobacco heart perhaps longer than -was necessary, addressing, as I am, a meeting of practitioners of -experience and not a class of clinical students. I have done so to -bring home to us an important consideration which we are all apt -to overlook in diagnosis and still more in treatment, namely, that -whether in an ordinary senile heart, or in a heart that is the seat -of chronic valvular disease, or in arterial degeneration, something -more than the pathological changes have in many instances to be -regarded--usually some entirely adventitious disturbance which alone -calls for treatment, such as indigestion, flatulence, worry, a -bronchial catarrh, or it may be free indulgence in tobacco, tea or -coffee. - - -THE HEART IN ALCOHOLISM. - -Let us now pass on to consider, from the clinical point of view, the -effect on the organs of circulation of another morbific influence -of a definite kind, namely, alcohol, or perhaps more correctly -alcoholism, leaving on one side the questions of form and strength -of the drink taken and its purity. - -The direct effects of alcohol on the heart and the blood-vessels are -by no means so easily determined as those of tobacco. In the first -place, they are complicated with the many indirect effects which it -produces on these organs by deranging the functions of alimentation -and assimilation, the nervous system and the kidneys, and with the -secondary effects on the vessels and heart of chronic nephritis -due to the same cause. In the second place, as we saw in my first -lecture, alcoholism is very commonly associated with nervous strain, -with gout and goutiness, with tobacco, with syphilis, and not -uncommonly with two, or more, or all of these together. Eliminating -as far as possible these sources of error by careful selection of -cases, I find that the alcoholic heart in middle and advanced life -presents clinical characters, as a whole, very different from those -of tobacco heart, which we have just studied. The most striking and -important of these are the evidences of actual pathological change -in the size of the heart and the condition of the myocardium. We -found no evidence that tobacco causes serious cardiac enlargement, -and neither may alcohol in quite young subjects, who present mainly -excited action both in force and in frequency. But of 28 cases of -alcoholic heart which I examined clinically in connection with the -present inquiry in older subjects, only two hearts were of ordinary -size (and as a matter of fact both of these patients were under -40 years of age). This result is in accord with my pathological -observations. For instance, I have carefully followed the condition -of the heart in an intemperate man of 43, and _post mortem_ found -the heart to weigh 17 ounces, to be universally dilated in all -its chambers, and to present enlargement of the mitral opening -without valvular lesion, corresponding with a weak apex systolic -murmur heard during life. These results are also in accord with -those in Dr. Maguire's cases of acute dilatation of the heart from -alcoholism, which he recorded as long ago as 1888[7] (when, I may -add, doubts were expressed of the correctness of his conclusions -by several of our best authorities on cardiac disease), and one of -which occurred in a man of 23. Dr. Mott has found fatty degeneration -of the myocardium in patients dying suddenly during alcoholism.[8] -With hardly an exception the præcordial impulse is weak--indeed, -it is often imperceptible; the sounds are small and feeble, and -may be almost inaudible; in 20 per cent. of my cases a weak apex -systolic murmur could be heard, varying with posture and from day -to day, significant, no doubt, of leakage through a dilated mitral -opening. The alcoholic heart is irregular and accelerated in about -half the cases. The pulse tension is usually low; in one-third of -the instances the radial artery was sclerosed; in one-fifth of them -there was slight albuminuria; the legs may be oedematous. The -complaints which the patient makes to us are commonly of palpitation -of the heart, faintness or actual faints, and præcordial pain; but -it is very interesting to observe that angina pectoris is rare in -the alcoholic as compared with the tobacco heart, in the ratio of 4 -to 15 per cent. With these cardiac symptoms proper there are usually -associated the sweats, coldness of the extremities, and depression, -sinking or lowness characteristic of alcoholism. But it is -unnecessary for me to fill in this outline sketch of the condition -of the victim of either acute, or sub-acute, or chronic alcoholism. -I would rather mention one form of acute alcoholic failure of the -heart of which I have recently seen a case, but which appears to -be rare. A middle-aged woman, at the end of each of her repeated -bouts of active alcoholism, has violent sickness; prostration passes -into collapse, and for 24 hours or more she lies flat on her back, -with all the phenomena of what may be called acute air-hunger. She -breathes loudly and deeply, at the rate of 36 per minute, with -groaning expiration. The expression is alarmed, despairing and -imploring; the nose is pinched; the surface is livid and cold; the -breath is cold; the pulse is practically imperceptible at the wrist; -and yet the præcordial impulse is both strong and extensive, and the -rate of the heart greatly accelerated. The condition is at once one -of collapse and urgent dyspnoea, quite as in one form of so-called -diabetic coma; and it is further remarkable in that it may pass off -suddenly after having lasted, as I have said, for many hours. It is -difficult to resist the conclusion that in such a condition as this -some product of alcohol, present in the blood, is the cause of the -remarkable phenomena. - - [7] Maguire, 'Trans. Clin. Soc. of London,' vol. xx, p. 235. - - [8] Mott, "Cardio-Vascular Nutrition and its Relation to Sudden - Death," _Practitioner_, xli, p. 161. - -The course of alcoholic heart in older subjects usually becomes -affected by the appearance of cirrhosis of the liver, Bright's -disease, neuritis, and possibly dementia. The method of termination -is very various, including ordinary cardiac failure with dropsy; -and sudden death occasionally occurs. Still, recovery is far from -being impossible, even after dropsy has made its appearance, for -the size of the heart may decline under strict abstinence from -alcohol, and the oedema disappear. This is a matter of great -practical interest, inasmuch as we know that, whilst the effect -of alcohol on the heart and circulation is for a time functional -only, it presently becomes truly nutritional, as in the cases I -have just narrated. The myocardium is not always beyond repair, -although it and the fine myelinated fibres of the vagus undergo -fatty degeneration according to Dr. Mott,[9] just as there are -changes in the pyramidal cells and fibres of the cerebral cortex in -the alcoholic; and the feebleness and irregularity of the heart are -analogues of the depression and confusion of the brain. - - [9] Mott, 'The Croonian Lectures on the Degeneration of the - Neurone,' p. 110, 1900. - - -GOUT. - -Of the many instances of disorder and disease of the heart and -arteries that I have met with in gouty subjects at or over 40 years -of age, I have made a careful study of 29 taken from my private -case-books. Twelve of these (10 M. + 2 F.) had suffered from -ordinary articular gout, the other 17 (6 M. + 11 F.) had irregular -gout, as defined in my first lecture. The average age was 62. In -no instance was there albuminuria. The physical condition of the -heart and arteries and the patient's complaints were remarkably -alike in the two groups. In 23 of the 29 the heart proved to be -enlarged, either on one or both sides. In less than half the number -the cardiac action was feeble; in a small number the impulse was -entirely imperceptible; the heart- and pulse- rate was ordinary; the -rhythm was but seldom irregular. It is a very remarkable fact that -in no fewer than 12 out of the 29 cases of gouty heart a systolic -murmur was to be heard over the aortic area, the manubrium and the -right carotid, significant of disease either of the aortic arch or -of the aortic valves--in every instance independently of rheumatism -or other obvious cause than gout. This result is an interesting -confirmation of the pathological observations of Dr. Norman Moore -and Sir Dyce Duckworth given by the latter,[10] and of the statement -of Murchison[11] of his experience "that atheroma of the arteries -at an unusually early period of life, and diseases of the aortic -valves which are not congenital, and are independent of injury -or rheumatism, are met with far oftener in persons who are the -subjects of the lithic acid dyscrasia, or who have had gout, than -in those who have had no such tendencies." In seven (25 per cent.) -of my cases a more or less developed systolic murmur was found -in the mitral area, significant either of valvular atheroma and -sclerosis or of leakage from ventricular dilatation. Very curiously -I have never met with aortic incompetence of gouty origin. When no -murmur exists the cardiac sounds are commonly somewhat feeble, and -the second sound may be of ringing quality--this more commonly in -goutiness than in developed gout. In agreement with this connection, -the radial pulse is more often tense in the subjects of irregular -than of regular gout[12]; altogether, high tension is found in more -than one-half of the cases. The great majority presented distinct -thickening of the arterial walls. As I suggested in our study of -the etiology, these pathological changes appear to be the result of -malnutrition of structures (the myocardium, valves and arteries) -worked at high pressure; and in addition to the local disturbance -of metabolism in the cardiac and arterial walls, which are fed with -gouty blood, there is the damaging effect on them of similar disease -of the _vasa vasorum_ and _vasa cordis_ or coronaries.[13] Besides -a distressing feeling of irregularity, fluttering or intermittency, -and dyspnoea on exertion, men who are the subjects of gouty heart -complain most frequently of præcordial pain; women more often of -palpitation and faintness or actual faints. In quite one-fourth -of all cases of gouty heart the pain is anginal, and such angina -may be of the most pronounced type. A friend of my own, aged 60, -began to suffer from gouty angina (diagnosed to be such by his -family physician 40 years ago) at the age of 20. Almost every year, -somewhat more frequently for the last 12 years of his life, he was -liable to be seized with intense pain in the left side of the chest, -which rapidly extended to the neck and down the left arm, with -tingling in the hand; a sense of great constriction in the chest; -faintness, and difficulty of breathing. He had immediately to rest, -whereupon the distress subsided; but it did not perfectly disappear -for hours. On different occasions also, in connection with these -anginal seizures, I have known him have free hæmoptysis, complete -unconsciousness, vomiting, and sudden violent evacuation of the -bowels. He also suffered from articular gout, and from irregular -gout in almost every possible form. - - [10] Dyce Duckworth, 'A Treatise on Gout,' 1889, p. 108. - - [11] Murchison, 'Clinical Lectures on Diseases of the Liver,' 3rd - edition, 1885, p. 637. - - [12] _Cf._ Clifford Allbutt, "Selections from the Lane Lectures," - _Philadelphia Med. Journ._, January 27th, 1900. - - [13] Mott, _Practitioner_, _loc. cit._, p. 169. - - -OBESITY AND GLYCOSURIA. - -Closely related to goutiness is a clinical type of disturbed -metabolism, mainly characterised by corpulence, a bulky, flabby -build, and glycosuria. Of this type, represented by 12 cases in my -series, nine had glycosuria and two albuminuria; eight were men; the -average age was 58. Only one had suffered from true articular gout. -Here, again, the interesting observation was made that no less than -three-fourths of the number had a systolic aortic murmur, none of -them a regurgitant aortic murmur, and nearly one-half of them an -ill-developed mitral systolic murmur. Thus there appears to be more -liability to atheroma in the gross corpulent diabetic even than in -the gouty man. In all the cases the heart appeared to be enlarged, -but accurate physical examination is difficult or impossible in -many of these subjects. The impulse was more often feeble than in -the gouty; the cardiac sounds were equally weak, and the second -aortic sound was occasionally accentuated. The pulse corresponded -with the gouty pulse in thickness and tension, but it was more often -found irregular and hurried. As for the complaints of corpulent and -diabetic patients, they prove to be very similar to those of gouty -individuals in respect of pain, but neither palpitation, faintness -nor irregularity was so often mentioned. - -It must not be understood from what I have just said in my account -of these cases that all disturbances of the heart in gouty subjects -progress to valvular or vascular degeneration, with associated -cardiac enlargement and degeneration. The friend whose case I have -just described at some length had led an active life, as I said, for -40 years; and, as I hope to show in my next lecture, the condition -is amenable to treatment if this is based on a correct appreciation -of the cause that is at work. But it is equally true that if correct -advice be not given, or if it be given but be neglected, as happens -so frequently, the endocardium and the aorta and other arteries -steadily degenerate, chronic interstitial nephritis makes its -appearance, and the patient dies either slowly from cardiac failure -or suddenly from cerebral hæmorrhage. - - -CARDIAC STRAIN. - -I will now proceed to consider the clinical characters of a class -of cases in which you, Sir, are particularly interested--strain -of the heart in middle and advanced life. To make this part of my -subject more plain, I will discuss in the first place acute strain -of the heart as it occurs after the fortieth year; afterwards I will -consider the condition of the heart and arteries at this age in -persons who have strained them in youth or early manhood. - -A man of 65, who came to me complaining of his heart, gave the -following account of the commencement of his trouble:--Four years -previously, on making a very hard stroke at golf (the ball was -bunkered), he was suddenly seized with a sensation of something -having happened in his heart. He played up to the next hole, but -now felt the chest oppressed; he sat down and got relief. This -experience was repeated, and he gave up the round. Walking home -two miles, he had to sit down occasionally with the same feeling. -Ever since that occurrence exertion had produced the same effect. -I found the ordinary physical signs of enlargement of both sides -of the heart; a scarcely perceptible impulse; the cardiac sounds -extremely feeble, the second being of a finely ringing quality; the -pulse tense, quiet and regular, but the radial artery by no means -sclerosed. The patient's principal complaints were of irregular -action of the heart, which troubled him on lying down or when he -was dyspeptic; and, as I have said, of post-sternal oppression on -exertion. This man had neither albuminuria nor emphysema, but he -had frequently suffered from ordinary articular gout. Belonging -to this type of cardiac strain I have notes in all of 11 cases, -which I will briefly summarise. Eight were men, three women; and -their average age was 56. In all but one of them the heart was -large, with feeble præcordial impulse; the sounds were small and -feeble; the aortic diastolic sound was often ringing; in but one -case was there a murmur--aortic systolic; with few exceptions the -rhythm and the rate of the heart were ordinary. In half the cases -the radial artery was sclerosed; in the majority the tension was -not increased. Persons who strain their heart after middle life -chiefly complain of præcordial oppression, dyspnoea on exertion, -a sense of palpitation and irregular action of the heart, and pain, -which may amount to angina; and they may tell us that distress -and disability in these different forms have troubled them for -years. You will have observed that the man whose case I have read -in particular was the subject of gout; and this brings me to the -interesting fact that of these 11 individuals seven were gouty. -We have already seen how greatly reduced is the resistance of the -cardio-vascular system in gouty subjects; and we are prepared for -the readiness with which their heart may be strained by exertion--a -matter of obvious importance prophylactically. In other cases not -included in this group the strain took the form of valvular injury, -or it affected hearts already the seats of old-standing valvular -lesions of rheumatic origin; but the present is not the occasion -to discuss these. Nor need I add that a not infrequent result -of acute strain of the aged heart, whether its valves have been -already damaged or its myocardium badly nourished, is sudden death. -Now, I can understand that some of my audience might object to -the application of the term "strain" to the effect of exertion in -gouty and senile hearts, just as Professor Clifford Allbutt, who is -universally recognised as the earliest and highest authority on this -subject, suggests that the clinical expression "strain of the heart" -relates only to comparatively young subjects free or nearly free -from degeneration.[14] It might be contended with great reason that -exertion in these subjects is not a cause of strain or dilatation of -the heart, but simply a test, as it were, or the proof, of cardiac -debility and disability. But when we come to consider cardiac strain -a little more closely, it may be just as easily maintained that -every dilated heart, every dilated cardiac chamber, every dilated -blood-vessel has been strained. Whether, on the one hand, valvular -disease, Bright's disease or emphysema, or, on the other hand, -myocardial degeneration, has disturbed that cardinal condition of -a normal circulation that the driving power must always exceed the -resistance ahead, over-distension and dilatation of the cavities, -with excessive stretching of their walls, constitute or consist in -mechanical strain. However, laying aside theoretical discussions -of this character, the great practical fact remains, that when the -aged and ill-nourished heart is over-distended from sudden and -severe exertion, neither the elastic nor the muscular tissues of -its walls can bear the strain; it becomes dilated; for the future it -acts at a mechanical disadvantage; and as often as this may occur -it suffers still more in its efficiency. On the other hand, it is -really in confirmation of this consideration, though apparently in -opposition to it, that the heart may diminish somewhat in size, and -præcordial distress disappear, under strict treatment continued for -a sufficient length of time. - - [14] Clifford Allbutt, 'System of Medicine,' v, p. 843. - - -STRAIN BEFORE FORTY. - -A more interesting group of cases than those which I have just -discussed is composed of persons who have strained their hearts in -youth or early manhood, have never been quite well since, and in -middle or advanced life are at last driven to us for help. Cases -of this character would furnish excellent material from which we -might attempt to judge of the after-effects of excess or abuse -of muscular exercise in the young. This is a tempting subject of -discussion, but one far too long and much too important to be taken -up casually at this time. Therefore, I will content myself with -submitting to you as plainly as I can certain facts bearing on it -that have come before me in my present inquiry, along with a few -simple observations of a practical bearing. First, then, let me -read to you the history of what I should call a typical case of the -kind. A man of 69 complains that as often as he walks any distance -or climbs a stair he is arrested by a distressing sense of having a -bar across the lower end of the sternum, breathlessness, irregular -palpitation of the heart, and a very little choking in the throat; -the discomfort has lately deserved the name of pain. His heart is -very large, the area of præcordial dulness being increased in all -directions and measuring transversely 7 inches. The impulse is -weak over the left ventricle, but definite in the epigastrium; the -sounds come in couples--moderately good and very weak respectively, -without murmur; and the radial artery is large and thick, with -rather low pressure and irregular rhythm. It turns out that for the -last 40 years these uncomfortable feelings have troubled the man -more or less, and that at three different periods of his life--at -31, at 42 and at 67--they increased so much as to incapacitate him -for many months, the first time with a sudden sense of something -snapping in the heart, the second time with a faint, and always, -as he believes, consequent on overwork. Now this man never had -rheumatism, nor gout, nor syphilis, and was always a temperate, -careful liver; and he volunteers the statement that he first felt -his heart at Cambridge, where he was captain of his College boat, -and was tried for the University boat but felt that he was not fit -for it. Belonging to this type of cardiac strain I have selected -11 cases. The heart is always found to be enlarged, and in about -one-half of the cases it is irregular. It may be weak and beating -at the ordinary rate, but in other instances it is increased both -in force and frequency. Only in quite exceptional cases did I meet -with endocardial murmurs in this group of old strained hearts; as a -rule the sounds were ordinary, with a disposition to accentuation of -the aortic second sound. High tension and sclerosis of the radial -artery were respectively found in about one-half of the cases. The -patients complain most commonly of a distressing sense of irregular -palpitation of the heart, and very commonly of præcordial pain, -but rarely of angina. Faintness also is sometimes mentioned. Let -me hasten to add, with respect to these cases, that they do not -include any instances of direct injury of the valves mechanically. -Rupture or stretching of the aortic and mitral valves during -exertion furnishes us with some very remarkable clinical cases; but -it is with parietal strain that we are concerned now--mechanical -over-stretching of the cardiac walls, which are thereafter left with -but a narrow margin of the elastic and muscular reserve required -by them to meet trying circumstances of any kind, particularly -exertion. The subjects of dilatation of the heart from mechanical -stress suffer by no means from what is commonly called "heart -disease," excepting in the worst cases, but yet they feel their -hearts comparatively, and it may be seriously, disabled. Naturally -they associate these feelings of disability with fresh attempts -at exercise or exertion, as in the case which I have just read. I -pointed out in my first lecture that such exertion is not by any -means connected with the patient's occupation or daily duties, but -quite often occurs during unwise attempts on his part to resume -at 50 the athletic exercises of his youth in order to reduce his -weight, relieve his liver, or dispel gout. It is not wonderful that -under such circumstances a permanently enlarged and badly-nourished -heart should become embarrassed, or even seriously deranged or -still further strained. I have known a man of 43, going straight -from London to the Alps, have not only præcordial distress but -dropsy of his legs after his first ascent in his regular holiday. -Indeed, the man who has reached later middle-life with his heart -enlarged by years of great bodily activity in youth, and settles -down quietly on retirement, let us say from the navy, sometimes -finds that ordinary exercise is sufficient to produce alarming -cardiac distress and curious loss of courage, obviously due to the -muscular tissue of the thickened cardiac walls having fallen quite -out of condition. How instructive, for instance, is the following -case:--A gentleman of 60, who has led from his boyhood upwards a -life of physical activity and at the same time of temperance, and -has suffered from neither syphilis nor rheumatism, but possibly from -a very mild attack of gout, settles in a relaxing provincial town, -continues to eat heartily, and considers that a little work in the -garden is sufficient exercise for him. He increases in weight, his -breath gets short, his heart flutters, and now he begins to get -anxious about his health, fancying, as he says, that he has all -sorts of diseases--a disposition to worry about himself which is -entirely new and provoking to him. I find his heart very large and -feeble, the cardiac sounds scarcely audible, and in the mitral area -a well-developed systolic murmur. The patient is ordered to reduce -his diet as a whole and in respect of carbo-hydrates, to return -carefully to walking exercise on the level, and to take a calomel -purge followed by a saline twice a week, and a mild strychnine -mixture. He improves, and continues to do so; is able to walk miles -without discomfort; and in the course of two months not only do -I find his heart reduced in size on physical examination, but I -fail to hear the apical murmur, which must have been produced by -dilatation of the left ventricle. The bearing of such a case as this -on the pathology, prevention and treatment of certain cases of heart -disease in old subjects will be obvious to all. - -We must be careful, however, to observe that neither unwise -abandonment of wholesome exercise, nor ill-advised return to -physical exertion, separately or in succession, can be regarded -as the only cause of the recrudescence of cardiac distress after -40 in those who have strained their circulation in youth. Any one -of the many circumstances that produce cardiac failure and dropsy -in chronic valvular disease may lead to embarrassment and fresh -dilatation of the simply enlarged heart: anæmia and chronic disease, -the acute specific fevers including pneumonia, emphysema, granular -kidney, gout, syphilis, tobacco and alcohol poisoning, as well as -anxiety and worry, and in women the advent of the menopause; and I -may say here parenthetically that pains at the heart in athletic -youths are sometimes due to the tobacco smoking in which they -often indulge socially when the exercise is finished--not to strain -at all. In these cases of old cardiac strain, as in every form of -chronic valvular disease and of chronic heart disease of all kinds, -not only the original and permanent lesion, but the recent and -probably temporary circumstance that caused the failure has to be -ascertained and fully respected in connection with prognosis and -treatment. - - -SYPHILIS. - -Syphilis appears to account for a very considerable proportion of -the more serious cases of heart disease which we meet with in older -subjects--excluding of course chronic valvular disease originating -remotely in endocarditis. But I ought to repeat here what I have -already mentioned, that syphilis as a cause of cardio-vascular -lesions is very often associated with other morbific influences, -particularly strain and alcohol. Of its position as the principal -cause of grave disease of the valves as distinguished from the walls -of the heart, originating in middle life, there can be no question. -No fewer than nine out of 28 cases, of which I have private notes, -were the subjects of double aortic disease; practically all the -others had a loud ringing second sound over the aorta, significant -of degeneration; pain of anginal type in half the cases was the -prominent complaint; and two-thirds of the subjects had sclerosis -of the radial artery. When we consider that syphilis does also -affect the myocardium primarily; that fibroid disease, chronic -aneurysm and fatty degeneration of the heart are all traceable to -specific disease of the coronaries in many instances; and, finally, -that many of the subjects of syphilitic cardio-vascular disease -have perished before 40, the magnitude of this cause can be fully -realised. I believe that the profession in general have not yet -woke up, if I may say so, to the gravity of this subject. How -seldom we inquire for a history of specific disease in patients -coming to us with cardiac disease in middle life! To no one, as -far as my reading goes, are we so much indebted for the truth on -this subject as to my friend and colleague Dr. Mott. Thirteen -years ago he published a paper on 21 cases of sudden death from -cardio-vascular disease, and in nine of these there was a history of -either actual or probable syphilis. What was of greater interest, -however, at that early date, he drew attention to the association -of syphilitic cardio-vascular lesions with Bright's disease in the -broad acceptation of the term. Dr. Mott's work in the interval on -syphilitic lesions of the arterial system of the brain has been so -brilliant, and is so generally known, that it requires nothing more -than this appreciative mention by me, and it saves me the trouble of -an excursion into the subjects of cerebral hæmorrhage and thrombosis -in connection with these lectures. - - -NERVOUS STRAIN. - -I confess that it is difficult to say much that is of real -diagnostic value on the clinical aspect of cardio-vascular disorders -and disease from nervous strain. As I remarked in discussing this -subject from the etiological point of view, several factors come -into play besides nervous excitement followed by exhaustion and -their effects on the heart, great vessels and cerebral arteries; -and the cases, therefore, are found to present a puzzling variety -of features. Certain clinical characters are, however, common to -the majority. Arterial tension is high; the radial artery is thick, -sometimes markedly so; the heart enlarges; and in about one-half of -the cases a systolic murmur is to be heard either in the aortic or -in the mitral area, significant of chronic endocardial lesions--all -readily intelligible results of cerebral strain in the light of -our knowledge of the innervation of the cardio-vascular system. I -have already pointed out that in some of these patients polyuria -and temporary albuminuria occur along with the high tension and -the increased action of the heart; but the heart may fail later -on. The direct cardiac symptoms of which they complain are of the -ordinary character, palpitation with accelerated cardiac frequency -and pain (not angina) being the most common at first, feelings of -indescribable discomfort and suffocation in the more advanced stage. -A great deal that I might have had to say on the very interesting -subjects of pseudo-angina, and the climacteric and pre-climacteric -disturbances of the circulation in women, I am reluctantly compelled -to omit from want of time. - - * * * * * - -After having reviewed, as I have attempted to do, the principal -clinical characters of the disorders and diseases of middle and -advanced life under their several causes, it may appear for a -moment strange that the most important of all the clinical types of -cardio-vascular degeneration has been mentioned only incidentally. -This is chronic Bright's disease, which, from its complex -pathological relations, its widespread effects on the heart and -circulation and the organs that they supply, and the far greater -gravity of these than those of any of the other causes which we have -studied (unless it be syphilis), is a subject of endless interest to -us all. Fortunately for me my immediate predecessor in this chair on -the medical side, our distinguished Fellow, Dr. Samuel West, took -for his subject the "Clinical Aspects of Granular Kidney," and thus -relieved me of a task which he was so much better able to discharge -than I. Emphysema must also be passed over with the single remark -that it is a very common accompaniment both of vascular and cardiac -degenerations. - -I trust you do not conclude that the description which I have just -given you of the clinical characters of these various disorders and -diseases of the heart is in any sense complete. It only relates to -the most prominent symptoms and signs as they present themselves to -us in what might be called the every-day life of the patient, at a -period in the history of his case precedent to failure. In all of -them there may occur occasional attacks of acute embarrassment of -the heart and lungs from one or more of a variety of causes, such -as indigestion, excitement or over-exertion. Sooner or later, also, -there occurs either cardiac dropsy--insidiously developed after -increasing local distress, growing dyspnoea and "bad nights"; or -Bright's disease; or cerebral thrombosis or hæmorrhage, or acute -myocardial failure with angina: or the patient dies from failure of -the heart in the course of some acute disease such as bronchitis or -pneumonia. Neither have I considered it necessary in this lecture to -dwell on some of the rarer phenomena occasionally met with, such as -tachycardia and bradycardia. I may have occasion to refer to them -next time in connection with prognosis. - - - - -LECTURE III. - - -MR. VICE-PRESIDENT AND GENTLEMEN,--In this, the concluding lecture -of the series, I will attempt to deal with the applications of -the facts and considerations which I submitted to you on the two -previous occasions when I had the honour to address you. I trust -that what I then laid before you proved to be of some interest. -Let us see now whether it is practically useful. However much the -etiology and pathology of the diseases and disorders of the heart -and arteries in middle and advanced life may deserve study as -matters of natural history, we should be disappointed if they could -not be turned to account in prognosis and treatment. These are the -subjects I propose to discuss this evening. - -Now, prognosis and treatment, to be rational and useful, have to be -based on as full and as correct a diagnosis as knowledge permits. -The present disposition is to fall short of this; to rest content -with an incomplete diagnosis. We say that the patient's "heart -is dilated," that he has "arterial degeneration," that there is -"fatty degeneration." But you will remember that we have found that -cardiac dilatation may be present in every kind of cardio-vascular -degeneration; that the arteries are naturally enlarged and thickened -after middle life, and that we refused to call these changes morbid. -Clearly, therefore, a purely anatomical diagnosis of this sort -is insufficient. If you are asked what the prognosis is of fatty -degeneration of the heart, you answer that you must first be told -whether syphilitic or gouty disease of the coronary arteries, or -strain, or alcoholism, or phosphorus-poisoning or anæmia is the -cause of it. When you are planning the treatment of dilatation of -the heart you first determine whether the dilatation is a result -of the stretching of a sound heart by overfilling during muscular -effort, or of the insufficient emptying of failing chambers with -degenerated and feeble walls. Obviously what we ought to determine -in these instances and in every instance is the origin of the -disease. The ultimate diagnosis to be reached for practical purposes -is the etiological diagnosis. - -Is this possible? Does our knowledge of the nature, characters and -course of these cardio-vascular affections enable us to say, after -investigating a case, what the kind of the pathological change is -that constitutes the disease, or in what respect the physiological -mechanisms are disordered? Can the cause of these degenerations of -the heart and arteries be determined in each instance? How is the -practitioner to proceed to do so? What method might be followed with -advantage in making a complete diagnosis of heart disease in older -subjects? - -A man of 60 consults us about his heart. He says that it has caused -him a good deal of concern lately. More specifically he describes -a sense of oppression behind the sternum as often as he exerts -himself, and palpitation with consciousness of irregular cardiac -action when he goes to bed. We inquire for other familiar cardiac -symptoms, such as pain, angina, fluttering, faintness, giddiness, -and a sense of impending death. We find that one or more are present -occasionally, and that they have increased in number and degree -during the last few months or years. Perhaps cough, nocturnal -orthopnoea and dropsy may be beginning to give trouble. The next -part of the inquiry relates to the patient's previous history -from childhood upwards. Which of the acute diseases has he had? -Acute rheumatism, chorea, scarlet fever, typhoid, diphtheria and -influenza must be mentioned individually, and in women the nature -of any puerperal disease from which they may have suffered. Gout, -irregular gout, gravel, eczema, sick headache, asthma must be -inquired after with the same minuteness, and so must syphilis. We -next hear an account of any accident which the patient may have met -with, such as a blow, or a fall from a horse or a carriage. This -brings us naturally to question him about his occupation and modes -of relaxation and amusements--whether active or sedentary, regular -or irregular, their characters otherwise, and their direct effects, -including strain. More difficult to elicit is a correct account of -the patient's habits--in respect of food, stimulants and tobacco, -and his manner of life generally. As I said in my first lecture, -this is an inquiry which the family practitioner has an opportunity -to carry out much more successfully than the hospital physician -or consultant. The family practitioner has known for years of his -cardiac patient's work and worries; it may be of his large eating, -of his secret drinking, of the history of syphilis in earlier years. -It is always well also to inquire after a family history of gout, -rheumatism and heart disease. A list of questions like this sounds -far more formidable than it is in reality. A few minutes suffice to -arrive at the truth. We already have a pretty fair notion what we -have to deal with, whether strain, gout, syphilis, tobacco, an old -rheumatic lesion, or a combination of two or more of these. - -We next proceed to physical examination, beginning with the pulse -and arteries, and passing on to the heart and associated structures. -The characters of the præcordial impulse--particularly the seat -of the apex-beat and the strength of the impulse--are closely (I -might almost say laboriously) investigated. We must never yield to -the temptation to disregard weakness or absence of the impulse. -Like many other negative signs it is apt to be overlooked. Then the -præcordial dulness is mapped out by means of light percussion. -Finally, auscultation reveals to us the presence or absence of -murmurs and the characters of the sounds--in the standing and -recumbent postures, and, if necessary, after a little exertion. The -relative loudness of the first and second sounds over the different -parts of the præcordia is particularly worthy of note. - -Now let us suppose that we have found a mitral systolic murmur. We -ask ourselves whether it is structural or whether it is functional, -that is, due to relaxation and dilatation of the ventricular walls. -If structural, with which (if any) of the diseases elicited in the -man's previous history would it correspond? Most probably with -gout or glycosuria. Thus we attempt to connect the lesion with -its cause, and the cause with its effects, and have reached the -ultimate diagnosis. So with other valvular murmurs: for example, -an aortic diastolic murmur proves to be related to syphilis. If -there be no murmur audible, we naturally think of dilatation with -failure, or of enlargement from strain, from Bright's disease, from -arterial sclerosis, from emphysema, from an insufficient or impure -blood-supply in the coronary arteries, from disordered innervation, -or from some rarer cause, such as adherent pericardium; and then, -with these associations in our minds, we review once more the -patient's history, and generally succeed in our diagnosis. - -Here let me recount the significance of the principal signs and -symptoms which I detailed to you in my last lecture, considered in -the reverse order on this occasion, some of which are of real value -in differentiating the causes of cardio-vascular degeneration. To -begin with negative facts: a mitral pre-systolic murmur is never -significant of a degenerative lesion. Secondly, when we meet with -an aortic diastolic murmur, whether alone or along with an aortic -systolic murmur, we may safely conclude that we have to deal with -something more than atheroma produced by regular or irregular gout -and associated metabolic disturbance, cardio-vascular disease of -nervous origin and alcoholic or tobacco heart, even if there be -evidence of the presence of one or more of these in the case. -Aortic incompetence developed in later life is the result of -syphilis, or of acute or chronic valvular strain; but, of course, -many instances of this lesion met with after the age of 40 can -be traced to juvenile endocarditis of rheumatic or other origin. -Always a serious lesion, aortic incompetence due to syphilis, or to -syphilis and strain, is particularly grave, as being so frequently -associated with coronary disease and consequent myocardial -degeneration--fatty or fibroid, acute softening, and sudden fatal -failure. A fully-developed basic systolic murmur, audible over the -aortic area and manubrium and along the course of the carotid, -is a very common sign of atheroma of the aortic arch and valves -and great vessels in association with regular or irregular gout, -diabetes, corpulence and allied disorders of nutrition. It is also -one of the physical signs of syphilitic and traumatic affections of -the aorta and aortic valves and of remote endocarditis. Further, -these lesions are so often accompanied by similar degenerations in -the coronary arteries and consequent myocardial degeneration, that -the basic systolic murmur ought at least to raise the suspicion -of this in the observer's mind. An ill-developed basic systolic -murmur is not uncommon in alcoholism, chronic Bright's disease and -nervous strain, but it is difficult to dissociate from anæmia. A -fully-developed systolic murmur audible in the mitral area, I mean -independently of ventriculo-auricular leakage in cardiac failure, -is usually traceable to early endocarditis of rheumatic or other -origin, rarely to injury, including ordinary juvenile strain of the -valves or walls, or to Graves's disease. But in some instances it -is unquestionably due to valvular atheroma and attendant sclerosis, -caused by gout or other disturbances of metabolism, including the -effects of free living; and in these instances the observer must -not overlook the possible association of coronary disease and fatty -degeneration. If a systolic mitral murmur prove to be somewhat -indefinite and affected by posture, cubitus and effort, to vary -under observation from day to day, and to disappear under treatment, -it is of no more value to us in differential diagnosis than that -it signifies relaxation and weakness, or disorderly action, of the -left ventricle, consequent on any one of the recognised causes of -failure or disturbance of the heart, including the different cardiac -poisons, overwork, anæmia, acute disease, poverty and the like, and -this whether in a heart previously sound or previously enlarged or -previously the seat of valvular disease. An accentuated ringing -second sound in the aortic area, or more extensively, is of great -value in the diagnosis of arterial tension and of aortic atheroma or -of both, but it is associated with far too many different causes to -be of much use in differential diagnosis. It should suggest a most -careful search for Bright's disease. Slight reduplication of the -first sound is common over the heart strained in youth and the heart -degenerated by alcoholism and metabolic disorders, but everyone -knows that it is not unusual in a variety of other conditions, -healthy and morbid. On the other hand, the _bruit de galop_, or -cantering rhythm of cardiac sounds--definite doubling of the first -sound followed by loud, accentuated, ringing second sound--is -practically pathognomonic of Bright's disease, and is one of the -most valuable, because one of the most ominous, of physical signs in -connection with the cardio-vascular system. A normally-sized heart -with irregularity, increased frequency, and a variable systolic -murmur in the mitral area, is characteristic of tobacco poisoning. A -heart enlarged on both sides, and acting irregularly without murmur, -is (apart from cardiac failure) suggestive of strain in early life. - -Cardiac symptoms taken individually are of less diagnostic value -than signs. No symptom is pathognomonic. Palpitation is a nearly -universal phenomenon of cardiac disease and disorder. Faintness and -actual faints are not uncommon in cases of early cardiac strain, -gouty heart, and nervous disturbances. Angina we meet with, you -will remember, in regular and irregular gout, tobacco heart, strain -(especially strain after 40), and in syphilis and alcoholism, -whilst pseudo-angina is extremely common in nervous women: thus -angina is of less diagnostic value than might have been expected. -A high-tension pulse I have found most often in Bright's disease, -in juvenile strain, and in cardio-vascular affections of nervous -origin; a low tension pulse in connection with alcoholic and tobacco -poisoning, and with senile strain. - -When we review these facts, I think we are entitled to conclude that -the physical signs and symptoms carefully determined by clinical -investigation may be confidently employed, along with the patient's -previous personal history, and the history of his present illness, -to differentiate from each other the causes of cardio-vascular -degeneration in individual cases. And, further, that they inform -us of the seat of at least some of the lesions, valvular, parietal -and vascular. A little trouble, patience and attentive observation -are all that are required to reach a complete or working diagnosis. -Now we may approach the great practical subjects of prognosis and -treatment with some confidence. - - -PROGNOSIS. - -Beginning with the simplest kind of cardio-vascular disorder, let us -see what the prognosis is in tobacco heart. You will have gathered -from what I had to say on this subject in my last lecture, and -indeed you know as men of observation and experience, that it is -comparatively favourable. All the cases I have had an opportunity to -watch did well, provided the cause of their distress was avoided and -the heart and vessels were otherwise healthy. Further, improvement -begins early, and it may be rapid and recovery complete; but you -will remember that one patient, whose case I detailed to you, -continued to have alarming angina for six months after giving up -tobacco. Recurrence attends resumption of the habit, but some of -its votaries contrive to continue to smoke just short of inducing -serious discomfort. Unless a successful effort at reform be made, -cardiac trouble may continue indefinitely. But even then I cannot -say that I have seen serious damage done by tobacco alone in -sound hearts, nor arterial sclerosis, as has been stated by some -authorities. - -An entirely different and most unfavourable estimate is to be formed -of the prospect of life in the alcoholic heart. Naturally, a certain -proportion of cases recover if the disease be of recent development, -the condition uncomplicated, and treatment faithfully carried -out. Unfortunately, as a rule, we have to deal with alcoholism in -which all these conditions of success are wanting. The habit is -established, other organs besides the heart are involved, other -diseases than alcoholism are present, and the patient has neither -the inclination nor the power to follow our advice. Cirrhosis, -neuritis, dementia complicate the cardiac degeneration, or, more -correctly, it complicates one or all of these. Chronic Bright's -disease is made to account for a number of deaths in the mortality -returns that strictly belong to alcoholism. Occasionally the end -comes suddenly from fatty degeneration, or in the course of some -acute disease; otherwise, as we have seen, by slow cardiac failure -and dropsy. - -Prognosis in gouty heart, including the heart of the man with -goutiness, glycosuria and other irregular forms of the disease, is -a subject of considerable practical difficulty. In my last lecture -I read to you a short account of the case of a friend of my own -who had had occasional attacks of gouty angina for 40 years. And -certainly a large proportion of the old ladies of 60 or 70, whom -you all have had as patients for years on end with weak heart -and systolic murmur in the aortic area, owe their disablement -to gout, if my observations are correct. The lesion proper of -the aorta and aortic valves in these cases is atheroma, but the -damage is accompanied with repair in the form of sclerosis, which, -by increasing the loudness of the bruit, adds unreasonably to -our anxiety about the case. Equally certain it is that patients -belonging to this class improve under treatment. Still, the -condition of arrest cannot go on indefinitely. In addition to -extrinsic dangers, particularly those of Bright's disease, cerebral -thrombosis and hæmorrhage, and bronchitis, failure of the heart -is liable to supervene and prove fatal from the gravest of all -intrinsic causes, namely, coronary degeneration. As this increases, -the myocardium is steadily more and more impoverished; its -contractile vigour declines, and residual dilatation of the chambers -sets in with mechanical congestion of the viscera. Complaints of -"the heart" increase, the breathing becomes oppressed, the face -assumes more and more the characteristic "cardiac" appearance, and -dropsy creeps up the lower limbs. Even then the prognosis is not -hopeless, for undoubtedly a certain proportion of cases of dropsy in -old persons with degenerated heart and vessels are still amenable to -rational treatment. But the case has occasionally a more dramatic -termination. As I was able to illustrate after my second lecture by -a specimen from the Museum of Charing Cross Hospital, a branch of -one of the coronary arteries that has been narrowed by atheroma for -an indefinite length of time, with consequent cardiac weakness and -discomfort, may any moment become thrombosed rapidly, apparently -in consequence of some passing depression or other unfavourable -influence, just as in thrombosis of degenerated cerebral vessels. -Fatal angina is the result. This is a point of great practical -importance--that sudden death will occur in old gouty subjects not -from the lesion of which a basic or an apical systolic murmur is the -evidence and which causes us concern, but from associated coronary -atheroma, which we probably never suspect; indeed, that it may occur -in those subjects with no murmur whatsoever to attract our attention -and excite our fears. - -Still more unfavourable must be the forecast in syphilitic lesions -of the heart and vessels. Of 18 of my cases in which the result was -known, only one-half improved under treatment, and 20 per cent. of -them died within a few years (some indeed within a few weeks) of the -discovery of their disease. Cardiac failure accounts for most of the -deaths, whether developed gradually with dropsy, which proves to be -intractable; or progressing rapidly with great cardiac distress, -including angina; or occurring suddenly, as it often does. Aneurysm -makes its appearance in other instances, of which the patient dies, -or he is carried off by general paralysis or Bright's disease. - -What prospect have we to hold out to the man who has strained the -walls of his heart by muscular effort? I believe that one can speak -with some confidence on this subject. The middle-aged patient who -over-stretched his cardiac walls as a youth may be comforted with -the opinion that the condition is not a fatal one. The average -duration of 11 cases of this order I found to have been 30 years -when they came under my observation; the minimum duration was nine -years, the maximum 50 years. This last case deserves particular -mention. The patient was first seen by me for failure of the heart -with cardiac dropsy, consequent on fresh breakdown after exertion -during a holiday; and it is most encouraging to observe that -compensation was restored by treatment, and that now, 12 months -after that event, he is not only alive, but able to carry on light -professional work. This case also illustrates what I have told you -respecting the course of the affection, and the prospect before the -patients, in long-standing strain--that there is continual liability -to fresh embarrassment of the heart during exertion, in which they -appear to have a lasting inclination to indulge. If they happen -to follow an occupation that entails occasional effort, or effort -with excitement and worry (if they happen, let us say, to be busy -practitioners of medicine), they suffer in the same way from attacks -of tachycardia, distressing palpitation and anxiety. Indeed, as I -pointed out in my second lecture, they are readily upset by other -influences besides these, including indigestion, to which the victim -of hurry and worry is peculiarly liable; and they must be prepared -to have to lead a life of comparative temperance and self-denial. - -Neither is strain of the heart for the first time after 40 by any -means so grave as might be expected. Of course, sudden muscular -effort occasionally accounts for sudden death in old men. But it -is astonishing how, under such circumstances, quite old persons do -recover from conditions of extreme distress lasting acutely for -half an hour--for instance, after running with a heavy bag to catch -a train. The majority of my patients described their condition as -improved after a time, but others relapsed; and on the whole the -correct prognosis is that they must expect to remain variously -disabled--that is, liable to præcordial distress and dyspnoea on -more than moderate exertion, or when subjected to circumstances of -other kinds that tax the heart. - -Cardio-vascular disorder and disease referable to nervous strain -pure and simple is amenable to treatment by complete and prolonged -rest or relaxation in the majority of instances. Still, death may -occur from sudden cardiac failure; or should advice be neglected -or soon forgotten, as happens so frequently in these subjects, -the attendant high arterial tension and vascular degeneration too -often end in cerebral lesions, with or without Bright's disease. Of -chronic Bright's disease itself and the associated cardio-vascular -changes in their prognostic aspects I need not speak, except to say -that along with syphilis it is by far the most hopeless of all these -affections. - -In attempting to forecast the life of a man who is the subject of -cardio-vascular degeneration in middle or advanced life, we must -not forget the possibility of the intercurrence of acute disease. -Here is a large subject for us as practical men--one far too large -and important for discussion here: the effect, for instance, of the -existence of enlargement of the heart and an irregular and thickened -pulse on the prognosis of influenza, or, let us say, on the chances -of a successful issue after operation. Very naturally, unsound -vessels and a murmur over the præcordia weigh heavily against the -prospect of recovery from pneumonia, for example; and yet how often -do we not find a patient of 70 with one or both of these disturbing -conditions come safely through such an illness! Here, again, I -believe it is in great measure the true nature of the old-standing -disease, not the physical signs such as irregularity of pulse or -mitral bruit, that ought to be taken into account. A heart enlarged -and a radial artery thickened by prolonged activity and nothing else -will suffice to carry a man safely through an attack of influenzal -pneumonia; but what chance is there for the chronic alcoholic under -similar circumstances, or for the subject of chronic Bright's -disease? - -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. - - [15] G. W. Balfour, 'The Senile Heart,' p. 236, 1894. - -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, dyspnoea 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? - - [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 - - - - - -End of the Project Gutenberg EBook of The Lettsomian Lectures 1900-1901, by -J. 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Mitchell Bruce. @@ -109,47 +109,7 @@ table { </style> </head> <body> - - -<pre> - -Project Gutenberg's The Lettsomian Lectures 1900-1901, by J. Mitchell Bruce - -This eBook is for the use of anyone anywhere at no cost and with -almost no restrictions whatsoever. You may copy it, give it away or -re-use it under the terms of the Project Gutenberg License included -with this eBook or online at www.gutenberg.org - - -Title: The Lettsomian Lectures 1900-1901 - DISEASES AND DISORDERS OF THE HEART AND ARTERIES IN MIDDLE - AND ADVANCED LIFE - -Author: J. Mitchell Bruce - -Release Date: September 21, 2013 [EBook #43780] - -Language: English - -Character set encoding: UTF-8 - -*** START OF THIS PROJECT GUTENBERG EBOOK THE LETTSOMIAN LECTURES 1900-1901 *** - - - - -Produced by Ian Deane, Julia Neufeld and the Online -Distributed Proofreading Team at http://www.pgdp.net - - - - - - -</pre> - - - +<div>*** START OF THE PROJECT GUTENBERG EBOOK 43780 ***</div> <hr class="chap" /> @@ -2644,380 +2604,6 @@ Med. Journ.</cite>, January 27th, 1900.</p></div> <p>Minor typographical errors have been corrected without note. Irregularities and inconsistencies in the text have been retained as printed.</p> </div> - - - - - - -<pre> - - - - - -End of the Project Gutenberg EBook of The Lettsomian Lectures 1900-1901, by -J. 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You may copy it, give it away or -re-use it under the terms of the Project Gutenberg License included -with this eBook or online at www.gutenberg.org - - -Title: The Lettsomian Lectures 1900-1901 - DISEASES AND DISORDERS OF THE HEART AND ARTERIES IN MIDDLE - AND ADVANCED LIFE - -Author: J. Mitchell Bruce - -Release Date: September 21, 2013 [EBook #43780] - -Language: English - -Character set encoding: ASCII - -*** START OF THIS PROJECT GUTENBERG EBOOK THE LETTSOMIAN LECTURES 1900-1901 *** - - - - -Produced by Ian Deane, Julia Neufeld and the Online -Distributed Proofreading Team at http://www.pgdp.net - - - - - - - -Transcriber's note: - -Text enclosed by underscores is in italics (_italics_). - -Small capital text has been replaced with all capitals. - -Minor typographical errors have been corrected without note. -Irregularities and inconsistencies in the text have been retained as -printed. - - * * * * * - - - - - HEART DISEASE - - IN - - MIDDLE AND ADVANCED AGE - - - - - The Lettsomian Lectures - - ON - - DISEASES AND DISORDERS - - OF THE - - HEART AND ARTERIES - - IN - - MIDDLE AND ADVANCED LIFE - - _Delivered before the Medical Society of London, Session 1900-1_ - - - BY - - J. MITCHELL BRUCE, M.A., LL.D., M.D., F.R.C.P., - - _Physician to Charing Cross Hospital; Consulting Physician to the - Hospital for Consumption and Diseases of the Chest, Brompton_ - - - LONDON: - HARRISON AND SONS, ST. MARTIN'S LANE - PRINTERS IN ORDINARY TO HIS MAJESTY - - 1902 - - - - - _To_ - - JOHN H. MORGAN, C.V.O., M.A. Oxon., F.R.C.S. Eng. - - _President of the Medical Society of London, 1900-1901 - - from his friend and colleague - - The Writer_ - - - - -CONTENTS - - - LECTURE I. - PAGE - - Introduction 1 - - Natural State of Heart and Arteries after 40 3 - - Causes of cardio-vascular disorder and disease 6 - - Physical Stress 6 - - Nervous Influences 8 - - Cardiac Poisons 9 - - Disturbances of Metabolism 9 - - Gout 9 - - Syphilis 10 - - Acute specific fevers 11 - - Chronic affections 11 - - Complex causes 11 - - Old-standing Rheumatic Lesions 13 - - Family heart 14 - - - LECTURE II. - - Clinical Characters and Course 14 - - Clinical Characters and Course of Tobacco Heart 15 - - Clinical Characters and Course of the Heart in Alcoholism 18 - - Clinical Characters and Course of the Heart in Gout 20 - - Clinical Characters and Course of the Heart in Obesity - and Glycosuria 22 - - Clinical Characters and Course of Cardiac Strain 23 - - Clinical Characters and Course of Cardiac Strain before 40 25 - - Clinical Characters and Course of Syphilis of the Heart 28 - - Clinical Characters and Course of cardio-vascular disease - from Nervous Strain 29 - - - LECTURE III. - - Diagnosis, Prognosis and Treatment 30 - - Differential Diagnosis 31 - - Value diagnostically of different physical signs 33 - - Value diagnostically of different symptoms 35 - - Prognosis 36 - - Treatment 37 - - Conclusion 50 - - - - -THE LETTSOMIAN LECTURES - -1900-1901 - - - - -LECTURE I. - - -MR. PRESIDENT AND GENTLEMEN,--My first duty this evening is to -thank you, which I do most heartily and gratefully, for the -honour you have done me by selecting me to deliver the Lettsomian -Lectures for the present year. My second duty is to spend as little -time as possible on preliminary remarks, for--as you, Sir, know, -having yourself occupied this distinguished place on a former -occasion--three hours are all too brief for useful presentation of -material which one has collected for a purpose like the present. In -selecting the subject of my Lectures I was mindful of the character -and objects of this Society. In the Medical Society of London there -is a fuller blending of men engaged in family practice with men -holding hospital appointments than is the case at most of the other -learned societies connected with our profession in London; and -there is here an opportunity for free communication of experience -and interchange of opinion between these two classes of our Fellows -which cannot fail to be profitable to both. Therefore, I have taken -up a subject of thoroughly practical interest; and not only this, -but I will attempt to present it to you, to put you in a position -to look at it, from the point of view of the practitioner. The -problem of the diseases and disorders of the heart and arteries -in middle and advanced life may be said to come before the family -practitioner every hour of his work, and to offer difficulties and -create a sense of responsibility or even anxiety which are not -sufficiently appreciated by the hospital physician. There comes -before him the case of one of his patients, an active business -man of 45, who has been seized with angina pectoris when hurrying -to the station after breakfast, or that of an old friend, whose -proposal for an increase of his insurance at 50 has been declined -because of arterial degeneration and polyuria; or he is asked to -say whether a man of 60, occupying an important and possibly -distinguished position in the community, ought to retire from public -life because he has occasional attacks of praecordial oppression -and a systolic murmur at the base of his heart. What, again, is he -to do for the stout, free-living man, just passing the meridian of -life, who consults him for weakness and depression, whose heart is -large and feeble, and the urine saccharine and slightly albuminous? -There is not one of my audience who has not met with such cases as -these many times in his practice, and a variety of other cases of -cardiac disorder and disease after 40, where the importance of the -individuals, the value of their lives, and the gravity of their -complaints and their prospects have exercised him very anxiously. -What is the prognosis in cases of this order? What can be done for -them in the way of treatment? These are the questions which we -would desire to answer usefully. The answer, it seems to me, can be -given only after an analysis and study of a considerable number of -instances of the kind, in respect of their origin, their clinical -characters and course, and the result. This is the method of inquiry -which I propose to follow. It will be a study of cardio-vascular -disease in older subjects from the clinical point of view, and it -will be approached not only from the ordinary clinical side as -it is approached in hospitals, that is, by an investigation of -symptoms and signs, but also and especially in the light of that -particular order of knowledge which the family practitioner has -learned to appreciate and has so intimate an opportunity to acquire -correctly--a knowledge of the origin or causes of the different -affections, which it is always difficult, and often impossible, for -the hospital physician to ascertain. For the same reason, although, -to be complete, a study of the diseases of the circulation at and -after middle life should include an account of the _post-mortem_ -characters found in fatal cases, and whilst the basis of the -account I submit to you will be essentially pathological, I shall -not attempt to describe the pathological anatomy and histology of -this group of lesions of the heart and arteries. This part of the -subject has been remarkably advanced during the last few years; -and even if I had the time and the necessary knowledge to deal -with it now, I should have nothing original in it to lay before -you. Indeed, if I may venture to say so, our attention lately has -been too much confined to the pathological states of the heart and -arteries and too little directed to the causes which produce them. -"Arterial sclerosis" is now an ordinary diagnosis in every-day -practice, as if it were sufficient for purposes of prognosis and -treatment to have determined that the radial artery is thicker and -longer and more dense than normal, without regard to the actual -nature of the pathological change, whether strain, or syphilitic, -or gouty, or otherwise. And in the same way the phrase "dilatation -of the heart" is now in everybody's mouth, irrespective of -considerations of its origin. Not only has the profession suddenly -woke up to the recognition of a form of enlargement of the heart -which was fully described fifty years ago by physicians in our own -country, but the public have made "dilated heart" a fashionable -disease which calls for the advice of a specialist and an annual -visit to a Continental spa. We ought to have advanced beyond this -stage of cardiac pathology long before this time. Besides, of how -much greater interest is it in our every-day work to study the -causes or circumstances that lead up to disease than the simple -state of disease itself! And there is in a study of this kind -an opportunity afforded to the family practitioner of advancing -Medicine--scientific, preventive and therapeutical--as surely as if -he were a pathologist in the _post-mortem_ room or laboratory. - -Before, however, examining the influences and circumstances which -disorder and damage the circulation in middle and advanced life, let -us see what the normal or natural state of the heart and arteries -is after 40. It has been ascertained that the different parts of -the circulatory apparatus pass through certain definite phases -of change in the different stages of that decline of existence -and energy which leads to senility and ends in death. We have to -thank Professor Beneke, of Marburg, for the results of a laborious -investigation of this subject which are generally accepted and which -I will attempt to summarise.[1] - - [1] F. W. Beneke, 'Die Altersdisposition.' - -We should all expect the cardio-vascular system to undergo important -changes with increasing age; but few of us would be prepared to -find that these changes are neither uniformly progressive nor -indeed continuously progressive in the same direction. To make -more easily intelligible the nature and as far as possible the -origin of these anatomical alterations in the heart and arteries -during the second half of life, I will first refer for a moment -to the circulation from 20 to 45. During this period of life the -blood-pressure is relatively high, reaching its maximum about 36; -the aorta and other large arteries increase in diameter from the -stress of the blood-pressure on their elastic walls, particularly -between 35 and 45, and the heart increases in size year after year -at a nearly uniform rate. We have in these facts anatomical evidence -of the great functional vigour and activity of the circulation in -manhood. At 45, which is practically the commencement of the period -with which we are concerned, remarkable changes occur. Whilst the -arteries continue to increase in circumference (somewhat more slowly -than before), the blood-pressure falls and the heart begins--almost -suddenly--to diminish in size; and these three features characterise -the circulation for the next 20 years, that is, until the age of -65. How is this fall in the size of the heart to be accounted for? -Partly by the widening of the arterial trunks and the consequent -fall of pressure. But not by these only; for although the arteries -had been widening even more rapidly between 20 and 45, the pressure -was actually at its maximum then and the heart large, and we shall -presently find other facts opposed to this view. The peripheral -resistance in the systemic arteries must fall from some other cause -or causes in middle age than the loss of elasticity of the arterial -walls, and these causes are probably reduction of mechanical stress, -due to comparative bodily relaxation, loss of vaso-motor tone in the -splanchnic area, and the chronic diseases of which the subjects have -died whose hearts and vessels are measured _post mortem_. During -this phase of life also, the blood becomes more venous in quality -and its haemoglobin value is lowered. - -At 65, other changes which occur in the heart and arteries are -not less striking than those which I have just described. The -decline of circulatory energy, and the effects of time itself -on the protoplasm of the cells of the body, have so lowered the -metabolic and functional energy of the tissues and organs and the -activity of the blood-supply, that a considerable proportion of the -capillary network becomes obsolete. The peripheral resistance is -thus increased, and the blood-pressure rises; therefore the heart -once more increases so much in size that at the end of the 10 years -(age 75) it is found as large as it was at 45, and at the same -time the haemoglobin value of the blood again proves to be higher. -During this period, also, the arteries continue to grow wider and -thicker and longer--another proof that the size of the heart is -not determined solely by their calibre. Regarded as a whole, the -process of senescence of the cardio-vascular system presents to us a -beautiful instance of anatomical readjustment and compensation--the -counterpart, in a way, of the growth of the circulation in energy -and activity during the period of full manhood. The arterial walls, -which have been stretched in their diameter and in their length by -exhaustion of their elasticity under the stress of cardiac systole, -are strengthened afresh by the development of stays formed of -fibroid and muscular tissues in the intima and media; and the heart -responds to the altered mechanical condition ahead of it in the -arteries, and to the increased peripheral resistance caused by the -obsolescence of many capillaries, by growing afresh. - -This account relates to the size of the arteries after 40; now let -us inquire what is the condition of their structural elements. The -changes described do not necessarily involve disease of the tissue -elements, unless we were to call every senile change morbid. My -friends Dr. Bosanquet and Dr. Mullings have given me an account of -the state of the heart and aorta in the bodies of 25 men, aged 40 -and upwards, examined in the _post-mortem_ room of Charing Cross -Hospital, who had died from accident or suicide. The average age -was 531/2 years, and the aorta presented some degree of atheroma -in half the cases. When we consider how very slight a change in the -arch of the aorta is habitually described as "atheroma," and that in -a few of the cases the valves were diseased and the heart enlarged, -we are justified in concluding that in the majority of persons of -53 the arteries are still sound. This result is in accord with that -obtained by the late Professor Humphry, who devoted his attention so -long and so successfully to the investigation of old age. He states -that in the great majority of cases the arterial system appears to -present a healthy condition in those who attain to great age.[2] -Even among the majority of centenarians the evidences of arterial -degeneration were not manifest.[3] And we know that we occasionally -meet with people of 80 and upwards whose pulses are unexceptionable, -beyond presenting a trace of thickening and enlargement. - - [2] Humphry, 'Old Age,' 1889, p. 23. - - [3] _Op. cit._, p. 48. - -For my present purpose, therefore, we may conclude that as age -advances, the arteries naturally become wider, longer and thicker, -and altogether larger than in early life; and that we must not -speak of "vascular degeneration" in an evil sense as often as we -find these conditions present. As for the heart, we know that it -may remain structurally sound, and is more often regular than -irregular, to the most advanced years of life. Conversely, these -facts suggest that actual diseases of the arteries and heart, that -is, other than the changes which are found in all persons after 45, -are not properly senile in their nature. As Professor Humphry said, -they are no part of, but are rather to be regarded as deviations -from, or morbid departures from, the natural phenomena.[4] They -must be the effects of pathological processes due to a variety of -pathogenetic influences which assail the circulation. Now we are in -a position to study these. - - [4] Humphry, 'Old Age,' 1889, p. 15. - -After the age of 40, many of the influences that threaten the heart -and arteries with disorder and disease are peculiar to this period -of life--that is, different and distinct from the causes of cardiac -and vascular affections in childhood, adolescence and manhood; -others of them have been encountered already, with or without -permanent damage as the result. I will now examine them in detail, -and at the same time refer to certain provisions with which the -heart and arteries are endowed for resisting them and recovering -naturally from their effects, as well as to the circumstances -which render these provisions abortive or insufficient, and thus -predispose to disease or indirectly determine its occurrence. - - * * * * * - -1. _Physical stress_ is still a definite cause of cardiac and -vascular damage during the second half of life, in the forms both -of sudden violent exertion and of ordinary laborious occupations. -I have met with instances of acute and serious strain at all ages -over 40, up to and even after 70. I am aware that I must speak on -this part of my subject--the evil effects of muscular exercise--with -great caution in the presence of you, Sir, our President, who -have long been recognised as one of the principal patrons in our -profession of athletic sports, and so highly distinguished yourself -in them at Oxford and in the inter-University contests. I assume -that you are unwilling to admit that muscular exercise is dangerous -to health. But I feel sure that you will agree with me that when the -man of 65 rushes from his breakfast-table to catch his train, or -the lady of 70 hurries up a hill in Wales to be in time for morning -service, or the middle-aged father on holiday, who has just started -a bicycle in order to reduce his weight, takes the pace from his son -of 17, the effect on the heart and arteries is likely to be serious. -I have notes of a good many cases of cardiac strain in middle-aged -and old persons from cycling; a very few from violent efforts -to drive at golf; a few from efforts at lifting or resisting -heavy weights; and one notable case in which a member of our own -profession, a man of 45, belonging to the Royal Army Medical Corps, -broke down with acute cardiac dilatation during General French's -memorable ride to relieve Kimberley. In some of my cases there was -no reason to believe that the heart was other than sound before the -strain; but in a majority of them (and I have analysed 40, of which -I have more or less full notes) one or more of the safeguards of -the circulation against strain were already defective or wanting. -What are these? In the heart, chiefly a high degree of extensibility -or elasticity of its tissues, permitting over-distension of the -chambers, with safety-valve action of the tricuspid in extreme -cases, and a sound and vigorous musculature to effect the increased -action, and if necessary the hypertrophy, which mechanical stress -demands--in a word, healthy, well-nourished cardiac walls. It is -an interesting fact that two-thirds of my cases of cardiac strain -in the second half of life presented also a history of gout, fully -developed or irregular--in other words, a history of perverted -metabolism. Equally striking is another fact in this connection: -that in many cases the occurrence of strain in middle or advanced -age was but the latest of a series of similar events as the result -of muscular effort for a period of 10, 20, 30, 40, or even 50 -years--in other words, the heart had been strained originally in -youth or early manhood, and had given serious trouble as often as -it was taxed again. Rowing or running at college was in a good many -instances given as the cause of the first strain. I need not do more -than mention previous valvular disease, usually of rheumatic origin, -as a condition powerfully predisposing to cardiac injury by physical -exertion. Excepting in this indirect way, rheumatism has no effect -in lowering the resistance of heart or vessels to mechanical stress. - -The principal safeguard which the arteries possess against strain -is, of course, the extensibility and elasticity of their tissues. -Unfortunately the metabolic disorders, including gout, which we have -just found weakening the cardiac walls, are amongst the commonest -causes of arterial degeneration also; and the two influences--gout -and strain--acting together no doubt are accountable for a -considerable number of cases of atheroma and chronic arteritis. It -naturally might occur to us that gout and exertion could not well -be associated, but this very consideration serves to explain their -mutual influence in straining the heart. It is unwise, ill-timed, -ill-planned muscular exercise that injures the circulation, most -often on the part of the middle-aged man, who, awaking to the -consciousness of growing fat and gouty, rushes inconsiderately to -violent exercise for relief. - -2. It is generally recognised that nervous excitement and other -_nervous influences_ tax the circulation; and endless phrases -and expressions, articulate and inarticulate, testify to the -universal belief in the close connection between the heart and the -emotions. Quite recently Dr. Leonard Hill and Dr. George Oliver -have demonstrated instrumentally the rise of blood-pressure that -accompanies cerebral activity.[5] No doubt many cases of disorder -and disease of the walls of the heart and arteries originate in -distress, worry, anxiety and protracted suspense; and the connection -is most often seen in middle and advanced life, because these -depressing emotions fall most heavily upon mankind at this period. -Of the instances which I have met with I will mention but one or -two by way of illustration. A member of the Reform Committee at -Johannesburg at the time of the Jameson Raid, who had been confined -in Pretoria Jail, came home sometime afterwards with the ordinary -symptoms and signs of fatty degeneration of the heart, and died -suddenly on the street. A detective officer who had tracked suspects -and criminals all over the world, facing great personal danger, -and on one occasion had to convey a parcel of dynamite found -near a Government office to a place of safety many miles away, -came under my care later on with arterial sclerosis and cerebral -thrombosis, for which no other cause but a life of adventure could -be discovered. These were cases of actual disease of the heart and -arterial system respectively; and I need not add that disturbances -or disorders of the circulation, of every degree and variety, the -result of nervous excitement or depression, come constantly under -our observation, especially in women. I would particularly mention, -however, a group of cardio-vascular troubles that lie between these -two extremes. I have frequently observed that persons of anxious -and energetic temperament, burthened with responsible work of a -heavy, constant and prolonged character, when they break down, -as they often do, present the clinical features of high tension: -the pulse is full, the heart is large, the second aortic sound is -loud and ringing; there is polyuria, and a trace of albumen may be -found. This disturbance of the circulation, strongly suggestive of -contracted kidney, is as common in women as in men--for instance, -in matrons of schools or hospitals. Nevertheless, however clear -the direct connection between nervous strain and cardio-vascular -disease may be in many instances, it is in other instances unreal, -or more correctly indirect only. This is a matter of great practical -importance. First, the nervous temperament often drives the subjects -of it to physical overwork in the form of incessant and prolonged -devotion to work, with insufficient hours of rest and sleep, and to -unwise attempts to remove nervous exhaustion by violent muscular -exercise, as we have just seen. In the second place, alcohol -undoubtedly plays an important part in many instances regarded -as overwork and worry and nervous exhaustion, both in men and in -women--alcohol taken to enable more work to be accomplished, to -steady the nerves, to promote sleep, to drive away care, or to -relieve the faintness which it has itself induced. And thirdly, -many of the complaints of nervous depression, lowness and worry are -really due to gout, to influenza, and the like, which are at the -same time the true causes of the cardiac symptoms. - - [5] Leonard Hill, Allbutt's 'System of Me inc,' vol. xii; George - Oliver, 'The Blood and Blood-Pressure,' p. 170, 1901. - -3. What I have just said in connection with nervous causes of -cardio-vascular affections brings us naturally to that important -group of agents which may be summarily called _extrinsic cardiac -poisons_--alcohol, tobacco, tea, coffee and lead. I will not -dwell on this subject at present, for there is no need to prove -the reality of the connection, and I shall have occasion to refer -to some of these poisons at greater length under the head of -diagnosis. Alcoholic heart occurs both in men and women; tobacco -heart is extraordinarily common in our own profession, and common -in clergymen and in retired members of the public services; tea-, -coffee-, and cocoa- poisoning I have met with principally in -students. - -4. There can be no question but that by far the most prolific causes -of cardio-vascular disorder and disease after 40 are _disturbances -of metabolism_, including gout--at any rate amongst the middle -and upper classes in this country. This period of life brings -with it in many instances comparative relaxation from work, and a -disposition to substitute quiet or even passive for active exercise; -and whilst the demands of growth and development on the alimentary -system have greatly declined, the pleasures of the table and ease -generally are too often indulged in as a privilege of advancing -years and the legitimate reward of previous years of work. The -results are functional disorders of the liver, gout in regular and -irregular forms, gravel, and the many associated disorders of the -muscular, nervous and other systems. At the same time the arterial -tension rises, for the body possesses a physiological provision for -eliminating the nitrogenous products of metabolism, whether normal -or abnormal, namely, the kidneys, the vaso-motor mechanism and the -heart. Stimulation of the vaso-motor centre by nitrogenous waste -raises the arterial pressure; the heart is excited to more vigorous -contraction (if necessary it hypertrophies); and the consequent -polyuria washes the intrinsic poisons out of the system. Thus it -happens that in metabolic disorders, from excessive or unwholesome -eating and drinking, the heart, vessels and kidneys are kept under -incessant strain; and, like other organs working under strain in the -gouty subject, they are the readiest to suffer--first from disorders -of many kinds, and ultimately, unless reform be enforced, from -cardio-vascular degeneration and chronic Bright's disease. - -Of the many cases of this kind that I have seen at all ages between -40 and 80 (and others before 40), the proportion of irregular gout -to acute articular gout was about 3 to 2. Under irregular gout -I include goutiness in its many forms--sick headache, eczema, -sciatica, lumbago, acid dyspepsia, irritable bladder, asthma, -insomnia, vertigo, depression, and the familiar complexion and -appearance generally of "the gouty individual," all variously -combined. - -In other cases the metabolic disturbances come before us not as -gout or even goutiness in the ordinary acceptation of the term, -but in the forms of obesity, of diabetes, of gravel, of irregular -albuminuria, and of the effects of large eating and free living in -general. - -5. _Syphilis_--that fruitful cause of vascular disease, and both -directly and indirectly of cardiac disease--has by no means ceased -to attack the organs of circulation after 40. Whatever the date of -the primary infection, syphilis is a standing danger to the heart -and arteries in the middle-aged man and even in declining years. -Thus, in 11 cases belonging to this group, the average age at which -they came under my observation (most of them but not all complaining -of cardiac distress) was 55. All of these were men. I ought to add -that in a considerable proportion of the cases either physical -strain, alcohol, tobacco or Bright's disease was associated with -syphilis in the etiology, and sometimes more than one of these. - -6. For the man and woman of forty years of age and upwards, most -of _the acute specific fevers_ are affairs of the past. But the -liability to several of them remains, and, very unfortunately, the -liability to those acute specific processes which may attack the -cardio-vascular system--influenza in particular, and less often -typhoid fever, rheumatism, diphtheria and pneumonia, as well as -septicaemia of different forms or kinds, which works havoc throughout -the entire circulation. I should have had more to say under this -head but for the fact that our distinguished Fellow and former -President, Dr. Sansom, has thoroughly investigated it, and on more -than one occasion laid the results before you. - -7. I will not occupy your time this evening in tracing the -origin of certain cases of cardio-vascular disease in middle and -advanced life to _chronic affections_ of different kinds. Besides -the obvious effects upon the heart, blood and blood-vessels, of -anaemia, exhaustion, &c., we meet with such grave lesions as fatty -degeneration from pernicious anaemia and other blood disorders; -profound circulatory derangements and occasionally valvular lesions -in Graves's disease, and others. - -8. I now pass on to _complex causes_. In addition to the definite -and distinct influences which I have mentioned as threatening the -heart in this stage of life, there are two which are intimately -associated with other causes of cardio-vascular disease, but still -deserve to stand out independently. The first of these is emphysema, -and along with it other chronic affections of the lungs and pleura, -which strain the right ventricle; the second is chronic Bright's -disease, which similarly strains the left ventricle. I shall have -frequent occasion to return to these two morbid states in different -parts of my subject. I mention them here to give them the position -which they deserve as influences that threaten the function and -still more the structure of the heart and arteries. They are often -associated with each other, and each or both of them with one -or more of the unfavourable influences I have just enumerated, -particularly alcohol, disordered metabolism and gout. And this -brings me to the many instances in which the different influences -that threaten the circulatory organs in middle and advanced life act -together in different combinations. Alcoholism is equally common -amongst the poor, whose circulation is subjected to mechanical -stress, whilst it is impoverished by want; the well-to-do, who lead -luxurious, sedentary enervating lives; and, as I have already -observed, the keen active business or professional man who overworks -his brain on stimulants. In this country at least, gout appears to -be all-pervading, and as an unfavourable influence on heart and -vessels it often cannot be dissociated from alcohol, sedentary -habits, worry, plumbism, Bright's disease and emphysema. - -Thus, in our study of combinations of morbific influences we come -to appreciate the evil effect of certain _occupations_ upon the -circulation in middle life. The business man is exposed to the -unhealthy actions on his heart of confinement to a close office -or shop, worry, irregular hasty feeding, alcoholic indulgence in -connection with his trade or profession, and unwise attempts at -violent muscular exercise at the week-end or in the holiday season; -or he may be guilty of entire disregard of the rules of bodily and -mental hygiene, and bring on in this way premature degeneration of -his cardio-vascular system. Still more numerous are the causes at -work in the production of "soldier's heart." We have but to picture -to ourselves, if we can, the physical strain, the mental excitement, -the bodily hardships--including exposure to both extremes of -temperature--and the coarse fare which have been the lot of many -thousands of our brave troops in the Boer war, to understand how the -fighting soldier "ages" quickly, and, in particular, ages in his -heart and arteries. Add to these unfavourable influences syphilis, -alcohol and tobacco (which, unfortunately, must be added in many -instances), and the chance of escape from disease of the circulation -in the soldier is practically _nil_. But "soldier's heart" is also -met with elsewhere than in the army. The clergyman from the slums -of London or other great city, who has lived and toiled and--it may -be said truly--has fought with various success through alternate -periods of excitement and depression, and has thus suffered much -both in mind and body, comes to us with high-tension pulse, a -tortuous radial artery, a large heart and a systolic murmur over -the aorta, and complains of an attack of angina. His wife, who has -laboured in the parish for years (she is 76, and still active in her -work of charity), has also a thickened radial artery, a large heart, -and a systolic basic murmur, with no discoverable cause of these -evidences of a diseased circulation but the life that she has led -amongst the poor around her. Perhaps such cases of cardio-vascular -disease might be most correctly said to be due to the wear and tear -of life. They are met with also in the traveller or explorer, who -has spent most of his life in search of adventure; and they are -found in a man who has never left home, but whose years have been -filled with the toil and anxiety of his position as an owner of -land, or with prolonged litigation. - - * * * * * - -Such are the principal natural influences which individually or -in different combinations threaten or assail the sound heart and -blood vessels after the age of 40. I have given but a broad, hasty -sketch of them entirely from my own recent observations, and I -know that I have omitted some which in your opinion might deserve -mention, but which possess no special interest in relation to this -period of life--for example, the agents of acute infections of -the endocardium, and also new growths, pregnancy and parturition. -Let me now sum up the results, and say that whatever changes the -cardio-vascular system may present in middle and advanced life, -beyond those which we have found to be natural to it at those -particular periods, are pathological--the result of physical stress, -nervous influences, extrinsic poisons, disturbances of metabolism, -syphilis, acute disease, or chronic disease; or are associated -with chronic nephritis, emphysema or different combinations of the -preceding causes, with various occupations or positions in life, or -with other influences of less importance. It is necessary, however, -to qualify this statement in two respects. In the first place, the -heart and vessels may have been so damaged already, that is, in -early life, that they fall victims to influences which, whether -in kind or in degree, would have been insufficient to produce -idiopathic disease of these organs. This brings me to the subject of -old-standing valvular disease (mostly rheumatic in origin), chronic -strain, and adherent pericardium in middle-aged and old subjects. -A considerable proportion of our cases are of this type, and they -have to be mentioned here for the sake of giving completeness to -the plan of arrangement, but they are outside the range of our -immediate subject. In the second place, hearts and arteries at 40 -that appear to the naked eye free from damage may be molecularly -weak, and unable to offer effective resistance even to influences -of an every-day character. I have now arrived at the last, and -certainly one of the most interesting, of the causes of disease of -the heart and arteries in middle and advanced life. There are some -persons whose hearts and arteries cannot carry them through the wear -and tear of what may be called ordinary life for more than 40 or 50 -years. The vital energy of the tissues of these organs is exhausted -prematurely; they are already old at 45; degeneration of the -muscle and other cells sets in early, reminding us of the essential -myopathic paralysis of children. This type of case is described as -"family heart," for it also runs in families--three, four, five, -or more members of which, as in a number of instances that I have -observed, may have all died suddenly of cardiac disease--some of -them at an early age. Similarly, it is not by any means unusual to -find quite young subjects, say of 30, with vessels already much -enlarged; and I may add, equally young subjects with their lungs -already emphysematous although there is no history of respiratory -strain, reminding us of the very common association of emphysema -with arterial sclerosis in old age. These cases of family heart and -premature arterial sclerosis are the links that connect disease of -the heart and arteries in middle and advanced life of definitely -pathological origin with the genuinely senile changes in the -tissue-elements which render existence untenable at last, and which -may be said to be the result of the exhaustion of their nutritional -activity by "the thousand natural shocks that flesh is heir to." - - - - -LECTURE II. - - -MR. PRESIDENT AND GENTLEMEN,--In my last lecture I presented to -you a brief account of the condition of the organs of circulation -between the ages of 40 and 75, and I then proceeded to direct your -attention to the principal influences which may disorder and damage -them during that period of life. I will now attempt to describe -the clinical characters and course of the affections of the heart -and arteries, as I have observed them, in connection with these -different influences respectively--whether gout, mechanical stress, -syphilis, or other. Thereafter, if time permits, I may be able to -examine the different symptoms and signs individually in order to -discover the value of each as a guide in diagnosis. - -Now, as I have already pointed out, the causes of cardio-vascular -disease in the second half of life are very often, indeed usually, -complex. It follows, therefore, that if we desire, as we do most -particularly, to discover the effects of each pathogenetic influence -as distinguished from the others, we must begin our study with the -simplest, or purest, or most definite of all, and proceed from it -towards those which are more difficult, as well as to combinations -of causes. It is easy to adopt this method in our present inquiry. - - -TOBACCO HEART. - -We have in tobacco a single distinct influence at work; one that is -universally acknowledged to affect the heart and vessels, and the -physiological action of which is understood; one, further, that can -be removed (perhaps not without some difficulty, for I have had a -patient plead for his pipe with tears in his eyes), and certainly -that can always be resumed with remarkable readiness--in a word, -a most favourable subject of observation by experiment. It is -well, too, to begin the study of tobacco heart in young men, whose -circulation is still structurally sound, and thereafter to follow -up the subject in middle-aged and old persons. Adopting this line -of inquiry, I have found that the uncomplicated effects of tobacco -on young healthy hearts, as they present themselves clinically, -are: palpitation in every instance; a sense of irregular action,[6] -post-sternal oppression and pain in half the cases; and in one out -of every eight sufferers either angina or uncomfortable sensations -in the left arm. Faintness or actual faints occurred in one-third, -and giddiness and a feeling of impending death in a smaller -proportion. Turning to the physical signs, the heart proves to be of -ordinary size in 50 per cent. of the patients; in a few it is very -slightly enlarged; the praecordial impulse is often very weak, but -occasionally increased in force and frequency, and almost as often -irregular as not; the pulse tension, with insignificant exceptions, -I have always found low. Very interesting, in the light of what I -shall tell you later on, is the fact that of 20 of these patients -complaining of the heart not one presented a cardiac murmur beyond a -weak mitral systolic bruit, varying with posture or cubitus. This is -in accordance with the teachings of pharmacology --that tobacco acts -on the terminal branches of the vagus. - - [6] A medical friend who has suffered from tobacco heart assures - me that at one period he could distinguish the contractions of the - auricles and ventricles. - -Now we are in a position to study the tobacco heart in a man of 40; -and again let us begin with a man who is sound, active, and healthy -otherwise. He complains of his heart, and recognises willingly -(for he belongs to our own profession), in the discomfort and -anxiety from which he suffers, the penalty of having smoked for -years the strongest and blackest tobacco that he could buy. Yet his -heart is not enlarged, and the cardiac sounds might be described -as ordinary were they not peculiarly irregular, the frequency -changing every moment and a falter occurring at short intervals. -There is not a trace of murmur to be found in connection with -the valves and orifices. At ages over 40 a clinical study of the -tobacco heart is highly instructive from a practical point of view. -Whilst palpitation is still the common complaint, pain, including -angina, is put forward more prominently, and so are faintness, -actual faints, a feeling of impending death, and a sense of cardiac -irregularity, each intermission being accompanied with a sudden -stab through the praecordia. Some of you will remember Mr. Barrie's -quaint account in 'My Lady Nicotine' of what he calls the horrors -of his smoking days, when the pain at his heart made him hold his -breath--"a sting" as he describes it, and he believed he was dying. -In these subjects the heart is more frequently found to be large and -feeble; the same weak systolic murmur is occasionally to be heard; -the radial pulse is often irregular, and the vessel wall naturally -thick. This, you will notice, is a combination of symptoms and signs -sufficient to alarm the casual observer. But when we examine it more -deliberately, in the light of our study of the tobacco heart in -young subjects, on the one hand, and of our knowledge of the normal -or natural condition of the heart and arteries at 60, on the other -hand, we are able to reassure ourselves and our patients. We are -justified in concluding not only that every cardio-vascular lesion -which may be found in tobacco smokers is not to be put to the credit -of tobacco, but, _vice versa_ (and this is of more interest to us in -our present inquiry), that every praecordial pain, angina, faintness, -or irregular pulse in a man of 60 with a full-sized heart is not to -be hastily regarded as evidences of grave disease without further -inquiry as to his habits. The cardiac enlargement and large pulse -may be nothing more than the result of a life of bodily and mental -activity: the praecordial distress may be the result only of tobacco. -How very necessary this caution is will be impressed upon your -consideration by the two following cases. The first is that of a man -of 60, actively engaged in professional pursuits, who first suffered -from praecordial pain of an alarming character four and a half years -ago, and has had attacks since, particularly during exertion and -after meals. One day last autumn, at the end of many hours' hard -work, cheered by at least 18 cigarettes, he was rushing off to dine -with a friend when he was suddenly seized with praecordial pain which -he described as fearful, radiating down the left arm. He broke into -a cold sweat, thought that his last hour had come, and for a short -time had impairment of consciousness. Shortly after this event he -took the advice of his doctors and gave up tobacco (shall I say for -a time?), and from that day to this, now six months, he has had no -further trouble with his heart. - -The second case is equally striking. A man of 55, of fairly active -disposition and somewhat full habit of body, was suddenly seized -with angina pectoris in October, 1899. The pain was of a dull -bursting character over the region of the heart, and it passed into -the left shoulder, down to the elbow, and settled particularly in -the wrist. At the same time there was pain in the upper maxillary -region. The heart slowed down from 75 to 50, and the sufferer felt -that he was dying. From that time anginal attacks occurred in -rapid succession, five, six, nine or even eleven in a single day; -occasionally they came on in the night. This experience continued -for nearly two months on end; indeed, it was six months before the -angina finally ceased. It was instantly relieved with amyl nitrite; -nitro-glycerin was unsuccessful. In the course of giving advice to -this patient I fortunately discovered that he had just laid in a -stock of 2,000 cigars. The line of treatment was obvious; and the -result has been, as I have said, complete recovery. - -I have dwelt on the subject of tobacco heart perhaps longer than -was necessary, addressing, as I am, a meeting of practitioners of -experience and not a class of clinical students. I have done so to -bring home to us an important consideration which we are all apt -to overlook in diagnosis and still more in treatment, namely, that -whether in an ordinary senile heart, or in a heart that is the seat -of chronic valvular disease, or in arterial degeneration, something -more than the pathological changes have in many instances to be -regarded--usually some entirely adventitious disturbance which alone -calls for treatment, such as indigestion, flatulence, worry, a -bronchial catarrh, or it may be free indulgence in tobacco, tea or -coffee. - - -THE HEART IN ALCOHOLISM. - -Let us now pass on to consider, from the clinical point of view, the -effect on the organs of circulation of another morbific influence -of a definite kind, namely, alcohol, or perhaps more correctly -alcoholism, leaving on one side the questions of form and strength -of the drink taken and its purity. - -The direct effects of alcohol on the heart and the blood-vessels are -by no means so easily determined as those of tobacco. In the first -place, they are complicated with the many indirect effects which it -produces on these organs by deranging the functions of alimentation -and assimilation, the nervous system and the kidneys, and with the -secondary effects on the vessels and heart of chronic nephritis -due to the same cause. In the second place, as we saw in my first -lecture, alcoholism is very commonly associated with nervous strain, -with gout and goutiness, with tobacco, with syphilis, and not -uncommonly with two, or more, or all of these together. Eliminating -as far as possible these sources of error by careful selection of -cases, I find that the alcoholic heart in middle and advanced life -presents clinical characters, as a whole, very different from those -of tobacco heart, which we have just studied. The most striking and -important of these are the evidences of actual pathological change -in the size of the heart and the condition of the myocardium. We -found no evidence that tobacco causes serious cardiac enlargement, -and neither may alcohol in quite young subjects, who present mainly -excited action both in force and in frequency. But of 28 cases of -alcoholic heart which I examined clinically in connection with the -present inquiry in older subjects, only two hearts were of ordinary -size (and as a matter of fact both of these patients were under -40 years of age). This result is in accord with my pathological -observations. For instance, I have carefully followed the condition -of the heart in an intemperate man of 43, and _post mortem_ found -the heart to weigh 17 ounces, to be universally dilated in all -its chambers, and to present enlargement of the mitral opening -without valvular lesion, corresponding with a weak apex systolic -murmur heard during life. These results are also in accord with -those in Dr. Maguire's cases of acute dilatation of the heart from -alcoholism, which he recorded as long ago as 1888[7] (when, I may -add, doubts were expressed of the correctness of his conclusions -by several of our best authorities on cardiac disease), and one of -which occurred in a man of 23. Dr. Mott has found fatty degeneration -of the myocardium in patients dying suddenly during alcoholism.[8] -With hardly an exception the praecordial impulse is weak--indeed, -it is often imperceptible; the sounds are small and feeble, and -may be almost inaudible; in 20 per cent. of my cases a weak apex -systolic murmur could be heard, varying with posture and from day -to day, significant, no doubt, of leakage through a dilated mitral -opening. The alcoholic heart is irregular and accelerated in about -half the cases. The pulse tension is usually low; in one-third of -the instances the radial artery was sclerosed; in one-fifth of them -there was slight albuminuria; the legs may be oedematous. The -complaints which the patient makes to us are commonly of palpitation -of the heart, faintness or actual faints, and praecordial pain; but -it is very interesting to observe that angina pectoris is rare in -the alcoholic as compared with the tobacco heart, in the ratio of 4 -to 15 per cent. With these cardiac symptoms proper there are usually -associated the sweats, coldness of the extremities, and depression, -sinking or lowness characteristic of alcoholism. But it is -unnecessary for me to fill in this outline sketch of the condition -of the victim of either acute, or sub-acute, or chronic alcoholism. -I would rather mention one form of acute alcoholic failure of the -heart of which I have recently seen a case, but which appears to -be rare. A middle-aged woman, at the end of each of her repeated -bouts of active alcoholism, has violent sickness; prostration passes -into collapse, and for 24 hours or more she lies flat on her back, -with all the phenomena of what may be called acute air-hunger. She -breathes loudly and deeply, at the rate of 36 per minute, with -groaning expiration. The expression is alarmed, despairing and -imploring; the nose is pinched; the surface is livid and cold; the -breath is cold; the pulse is practically imperceptible at the wrist; -and yet the praecordial impulse is both strong and extensive, and the -rate of the heart greatly accelerated. The condition is at once one -of collapse and urgent dyspnoea, quite as in one form of so-called -diabetic coma; and it is further remarkable in that it may pass off -suddenly after having lasted, as I have said, for many hours. It is -difficult to resist the conclusion that in such a condition as this -some product of alcohol, present in the blood, is the cause of the -remarkable phenomena. - - [7] Maguire, 'Trans. Clin. Soc. of London,' vol. xx, p. 235. - - [8] Mott, "Cardio-Vascular Nutrition and its Relation to Sudden - Death," _Practitioner_, xli, p. 161. - -The course of alcoholic heart in older subjects usually becomes -affected by the appearance of cirrhosis of the liver, Bright's -disease, neuritis, and possibly dementia. The method of termination -is very various, including ordinary cardiac failure with dropsy; -and sudden death occasionally occurs. Still, recovery is far from -being impossible, even after dropsy has made its appearance, for -the size of the heart may decline under strict abstinence from -alcohol, and the oedema disappear. This is a matter of great -practical interest, inasmuch as we know that, whilst the effect -of alcohol on the heart and circulation is for a time functional -only, it presently becomes truly nutritional, as in the cases I -have just narrated. The myocardium is not always beyond repair, -although it and the fine myelinated fibres of the vagus undergo -fatty degeneration according to Dr. Mott,[9] just as there are -changes in the pyramidal cells and fibres of the cerebral cortex in -the alcoholic; and the feebleness and irregularity of the heart are -analogues of the depression and confusion of the brain. - - [9] Mott, 'The Croonian Lectures on the Degeneration of the - Neurone,' p. 110, 1900. - - -GOUT. - -Of the many instances of disorder and disease of the heart and -arteries that I have met with in gouty subjects at or over 40 years -of age, I have made a careful study of 29 taken from my private -case-books. Twelve of these (10 M. + 2 F.) had suffered from -ordinary articular gout, the other 17 (6 M. + 11 F.) had irregular -gout, as defined in my first lecture. The average age was 62. In -no instance was there albuminuria. The physical condition of the -heart and arteries and the patient's complaints were remarkably -alike in the two groups. In 23 of the 29 the heart proved to be -enlarged, either on one or both sides. In less than half the number -the cardiac action was feeble; in a small number the impulse was -entirely imperceptible; the heart- and pulse- rate was ordinary; the -rhythm was but seldom irregular. It is a very remarkable fact that -in no fewer than 12 out of the 29 cases of gouty heart a systolic -murmur was to be heard over the aortic area, the manubrium and the -right carotid, significant of disease either of the aortic arch or -of the aortic valves--in every instance independently of rheumatism -or other obvious cause than gout. This result is an interesting -confirmation of the pathological observations of Dr. Norman Moore -and Sir Dyce Duckworth given by the latter,[10] and of the statement -of Murchison[11] of his experience "that atheroma of the arteries -at an unusually early period of life, and diseases of the aortic -valves which are not congenital, and are independent of injury -or rheumatism, are met with far oftener in persons who are the -subjects of the lithic acid dyscrasia, or who have had gout, than -in those who have had no such tendencies." In seven (25 per cent.) -of my cases a more or less developed systolic murmur was found -in the mitral area, significant either of valvular atheroma and -sclerosis or of leakage from ventricular dilatation. Very curiously -I have never met with aortic incompetence of gouty origin. When no -murmur exists the cardiac sounds are commonly somewhat feeble, and -the second sound may be of ringing quality--this more commonly in -goutiness than in developed gout. In agreement with this connection, -the radial pulse is more often tense in the subjects of irregular -than of regular gout[12]; altogether, high tension is found in more -than one-half of the cases. The great majority presented distinct -thickening of the arterial walls. As I suggested in our study of -the etiology, these pathological changes appear to be the result of -malnutrition of structures (the myocardium, valves and arteries) -worked at high pressure; and in addition to the local disturbance -of metabolism in the cardiac and arterial walls, which are fed with -gouty blood, there is the damaging effect on them of similar disease -of the _vasa vasorum_ and _vasa cordis_ or coronaries.[13] Besides -a distressing feeling of irregularity, fluttering or intermittency, -and dyspnoea on exertion, men who are the subjects of gouty heart -complain most frequently of praecordial pain; women more often of -palpitation and faintness or actual faints. In quite one-fourth -of all cases of gouty heart the pain is anginal, and such angina -may be of the most pronounced type. A friend of my own, aged 60, -began to suffer from gouty angina (diagnosed to be such by his -family physician 40 years ago) at the age of 20. Almost every year, -somewhat more frequently for the last 12 years of his life, he was -liable to be seized with intense pain in the left side of the chest, -which rapidly extended to the neck and down the left arm, with -tingling in the hand; a sense of great constriction in the chest; -faintness, and difficulty of breathing. He had immediately to rest, -whereupon the distress subsided; but it did not perfectly disappear -for hours. On different occasions also, in connection with these -anginal seizures, I have known him have free haemoptysis, complete -unconsciousness, vomiting, and sudden violent evacuation of the -bowels. He also suffered from articular gout, and from irregular -gout in almost every possible form. - - [10] Dyce Duckworth, 'A Treatise on Gout,' 1889, p. 108. - - [11] Murchison, 'Clinical Lectures on Diseases of the Liver,' 3rd - edition, 1885, p. 637. - - [12] _Cf._ Clifford Allbutt, "Selections from the Lane Lectures," - _Philadelphia Med. Journ._, January 27th, 1900. - - [13] Mott, _Practitioner_, _loc. cit._, p. 169. - - -OBESITY AND GLYCOSURIA. - -Closely related to goutiness is a clinical type of disturbed -metabolism, mainly characterised by corpulence, a bulky, flabby -build, and glycosuria. Of this type, represented by 12 cases in my -series, nine had glycosuria and two albuminuria; eight were men; the -average age was 58. Only one had suffered from true articular gout. -Here, again, the interesting observation was made that no less than -three-fourths of the number had a systolic aortic murmur, none of -them a regurgitant aortic murmur, and nearly one-half of them an -ill-developed mitral systolic murmur. Thus there appears to be more -liability to atheroma in the gross corpulent diabetic even than in -the gouty man. In all the cases the heart appeared to be enlarged, -but accurate physical examination is difficult or impossible in -many of these subjects. The impulse was more often feeble than in -the gouty; the cardiac sounds were equally weak, and the second -aortic sound was occasionally accentuated. The pulse corresponded -with the gouty pulse in thickness and tension, but it was more often -found irregular and hurried. As for the complaints of corpulent and -diabetic patients, they prove to be very similar to those of gouty -individuals in respect of pain, but neither palpitation, faintness -nor irregularity was so often mentioned. - -It must not be understood from what I have just said in my account -of these cases that all disturbances of the heart in gouty subjects -progress to valvular or vascular degeneration, with associated -cardiac enlargement and degeneration. The friend whose case I have -just described at some length had led an active life, as I said, for -40 years; and, as I hope to show in my next lecture, the condition -is amenable to treatment if this is based on a correct appreciation -of the cause that is at work. But it is equally true that if correct -advice be not given, or if it be given but be neglected, as happens -so frequently, the endocardium and the aorta and other arteries -steadily degenerate, chronic interstitial nephritis makes its -appearance, and the patient dies either slowly from cardiac failure -or suddenly from cerebral haemorrhage. - - -CARDIAC STRAIN. - -I will now proceed to consider the clinical characters of a class -of cases in which you, Sir, are particularly interested--strain -of the heart in middle and advanced life. To make this part of my -subject more plain, I will discuss in the first place acute strain -of the heart as it occurs after the fortieth year; afterwards I will -consider the condition of the heart and arteries at this age in -persons who have strained them in youth or early manhood. - -A man of 65, who came to me complaining of his heart, gave the -following account of the commencement of his trouble:--Four years -previously, on making a very hard stroke at golf (the ball was -bunkered), he was suddenly seized with a sensation of something -having happened in his heart. He played up to the next hole, but -now felt the chest oppressed; he sat down and got relief. This -experience was repeated, and he gave up the round. Walking home -two miles, he had to sit down occasionally with the same feeling. -Ever since that occurrence exertion had produced the same effect. -I found the ordinary physical signs of enlargement of both sides -of the heart; a scarcely perceptible impulse; the cardiac sounds -extremely feeble, the second being of a finely ringing quality; the -pulse tense, quiet and regular, but the radial artery by no means -sclerosed. The patient's principal complaints were of irregular -action of the heart, which troubled him on lying down or when he -was dyspeptic; and, as I have said, of post-sternal oppression on -exertion. This man had neither albuminuria nor emphysema, but he -had frequently suffered from ordinary articular gout. Belonging -to this type of cardiac strain I have notes in all of 11 cases, -which I will briefly summarise. Eight were men, three women; and -their average age was 56. In all but one of them the heart was -large, with feeble praecordial impulse; the sounds were small and -feeble; the aortic diastolic sound was often ringing; in but one -case was there a murmur--aortic systolic; with few exceptions the -rhythm and the rate of the heart were ordinary. In half the cases -the radial artery was sclerosed; in the majority the tension was -not increased. Persons who strain their heart after middle life -chiefly complain of praecordial oppression, dyspnoea on exertion, -a sense of palpitation and irregular action of the heart, and pain, -which may amount to angina; and they may tell us that distress -and disability in these different forms have troubled them for -years. You will have observed that the man whose case I have read -in particular was the subject of gout; and this brings me to the -interesting fact that of these 11 individuals seven were gouty. -We have already seen how greatly reduced is the resistance of the -cardio-vascular system in gouty subjects; and we are prepared for -the readiness with which their heart may be strained by exertion--a -matter of obvious importance prophylactically. In other cases not -included in this group the strain took the form of valvular injury, -or it affected hearts already the seats of old-standing valvular -lesions of rheumatic origin; but the present is not the occasion -to discuss these. Nor need I add that a not infrequent result -of acute strain of the aged heart, whether its valves have been -already damaged or its myocardium badly nourished, is sudden death. -Now, I can understand that some of my audience might object to -the application of the term "strain" to the effect of exertion in -gouty and senile hearts, just as Professor Clifford Allbutt, who is -universally recognised as the earliest and highest authority on this -subject, suggests that the clinical expression "strain of the heart" -relates only to comparatively young subjects free or nearly free -from degeneration.[14] It might be contended with great reason that -exertion in these subjects is not a cause of strain or dilatation of -the heart, but simply a test, as it were, or the proof, of cardiac -debility and disability. But when we come to consider cardiac strain -a little more closely, it may be just as easily maintained that -every dilated heart, every dilated cardiac chamber, every dilated -blood-vessel has been strained. Whether, on the one hand, valvular -disease, Bright's disease or emphysema, or, on the other hand, -myocardial degeneration, has disturbed that cardinal condition of -a normal circulation that the driving power must always exceed the -resistance ahead, over-distension and dilatation of the cavities, -with excessive stretching of their walls, constitute or consist in -mechanical strain. However, laying aside theoretical discussions -of this character, the great practical fact remains, that when the -aged and ill-nourished heart is over-distended from sudden and -severe exertion, neither the elastic nor the muscular tissues of -its walls can bear the strain; it becomes dilated; for the future it -acts at a mechanical disadvantage; and as often as this may occur -it suffers still more in its efficiency. On the other hand, it is -really in confirmation of this consideration, though apparently in -opposition to it, that the heart may diminish somewhat in size, and -praecordial distress disappear, under strict treatment continued for -a sufficient length of time. - - [14] Clifford Allbutt, 'System of Medicine,' v, p. 843. - - -STRAIN BEFORE FORTY. - -A more interesting group of cases than those which I have just -discussed is composed of persons who have strained their hearts in -youth or early manhood, have never been quite well since, and in -middle or advanced life are at last driven to us for help. Cases -of this character would furnish excellent material from which we -might attempt to judge of the after-effects of excess or abuse -of muscular exercise in the young. This is a tempting subject of -discussion, but one far too long and much too important to be taken -up casually at this time. Therefore, I will content myself with -submitting to you as plainly as I can certain facts bearing on it -that have come before me in my present inquiry, along with a few -simple observations of a practical bearing. First, then, let me -read to you the history of what I should call a typical case of the -kind. A man of 69 complains that as often as he walks any distance -or climbs a stair he is arrested by a distressing sense of having a -bar across the lower end of the sternum, breathlessness, irregular -palpitation of the heart, and a very little choking in the throat; -the discomfort has lately deserved the name of pain. His heart is -very large, the area of praecordial dulness being increased in all -directions and measuring transversely 7 inches. The impulse is -weak over the left ventricle, but definite in the epigastrium; the -sounds come in couples--moderately good and very weak respectively, -without murmur; and the radial artery is large and thick, with -rather low pressure and irregular rhythm. It turns out that for the -last 40 years these uncomfortable feelings have troubled the man -more or less, and that at three different periods of his life--at -31, at 42 and at 67--they increased so much as to incapacitate him -for many months, the first time with a sudden sense of something -snapping in the heart, the second time with a faint, and always, -as he believes, consequent on overwork. Now this man never had -rheumatism, nor gout, nor syphilis, and was always a temperate, -careful liver; and he volunteers the statement that he first felt -his heart at Cambridge, where he was captain of his College boat, -and was tried for the University boat but felt that he was not fit -for it. Belonging to this type of cardiac strain I have selected -11 cases. The heart is always found to be enlarged, and in about -one-half of the cases it is irregular. It may be weak and beating -at the ordinary rate, but in other instances it is increased both -in force and frequency. Only in quite exceptional cases did I meet -with endocardial murmurs in this group of old strained hearts; as a -rule the sounds were ordinary, with a disposition to accentuation of -the aortic second sound. High tension and sclerosis of the radial -artery were respectively found in about one-half of the cases. The -patients complain most commonly of a distressing sense of irregular -palpitation of the heart, and very commonly of praecordial pain, -but rarely of angina. Faintness also is sometimes mentioned. Let -me hasten to add, with respect to these cases, that they do not -include any instances of direct injury of the valves mechanically. -Rupture or stretching of the aortic and mitral valves during -exertion furnishes us with some very remarkable clinical cases; but -it is with parietal strain that we are concerned now--mechanical -over-stretching of the cardiac walls, which are thereafter left with -but a narrow margin of the elastic and muscular reserve required -by them to meet trying circumstances of any kind, particularly -exertion. The subjects of dilatation of the heart from mechanical -stress suffer by no means from what is commonly called "heart -disease," excepting in the worst cases, but yet they feel their -hearts comparatively, and it may be seriously, disabled. Naturally -they associate these feelings of disability with fresh attempts -at exercise or exertion, as in the case which I have just read. I -pointed out in my first lecture that such exertion is not by any -means connected with the patient's occupation or daily duties, but -quite often occurs during unwise attempts on his part to resume -at 50 the athletic exercises of his youth in order to reduce his -weight, relieve his liver, or dispel gout. It is not wonderful that -under such circumstances a permanently enlarged and badly-nourished -heart should become embarrassed, or even seriously deranged or -still further strained. I have known a man of 43, going straight -from London to the Alps, have not only praecordial distress but -dropsy of his legs after his first ascent in his regular holiday. -Indeed, the man who has reached later middle-life with his heart -enlarged by years of great bodily activity in youth, and settles -down quietly on retirement, let us say from the navy, sometimes -finds that ordinary exercise is sufficient to produce alarming -cardiac distress and curious loss of courage, obviously due to the -muscular tissue of the thickened cardiac walls having fallen quite -out of condition. How instructive, for instance, is the following -case:--A gentleman of 60, who has led from his boyhood upwards a -life of physical activity and at the same time of temperance, and -has suffered from neither syphilis nor rheumatism, but possibly from -a very mild attack of gout, settles in a relaxing provincial town, -continues to eat heartily, and considers that a little work in the -garden is sufficient exercise for him. He increases in weight, his -breath gets short, his heart flutters, and now he begins to get -anxious about his health, fancying, as he says, that he has all -sorts of diseases--a disposition to worry about himself which is -entirely new and provoking to him. I find his heart very large and -feeble, the cardiac sounds scarcely audible, and in the mitral area -a well-developed systolic murmur. The patient is ordered to reduce -his diet as a whole and in respect of carbo-hydrates, to return -carefully to walking exercise on the level, and to take a calomel -purge followed by a saline twice a week, and a mild strychnine -mixture. He improves, and continues to do so; is able to walk miles -without discomfort; and in the course of two months not only do -I find his heart reduced in size on physical examination, but I -fail to hear the apical murmur, which must have been produced by -dilatation of the left ventricle. The bearing of such a case as this -on the pathology, prevention and treatment of certain cases of heart -disease in old subjects will be obvious to all. - -We must be careful, however, to observe that neither unwise -abandonment of wholesome exercise, nor ill-advised return to -physical exertion, separately or in succession, can be regarded -as the only cause of the recrudescence of cardiac distress after -40 in those who have strained their circulation in youth. Any one -of the many circumstances that produce cardiac failure and dropsy -in chronic valvular disease may lead to embarrassment and fresh -dilatation of the simply enlarged heart: anaemia and chronic disease, -the acute specific fevers including pneumonia, emphysema, granular -kidney, gout, syphilis, tobacco and alcohol poisoning, as well as -anxiety and worry, and in women the advent of the menopause; and I -may say here parenthetically that pains at the heart in athletic -youths are sometimes due to the tobacco smoking in which they -often indulge socially when the exercise is finished--not to strain -at all. In these cases of old cardiac strain, as in every form of -chronic valvular disease and of chronic heart disease of all kinds, -not only the original and permanent lesion, but the recent and -probably temporary circumstance that caused the failure has to be -ascertained and fully respected in connection with prognosis and -treatment. - - -SYPHILIS. - -Syphilis appears to account for a very considerable proportion of -the more serious cases of heart disease which we meet with in older -subjects--excluding of course chronic valvular disease originating -remotely in endocarditis. But I ought to repeat here what I have -already mentioned, that syphilis as a cause of cardio-vascular -lesions is very often associated with other morbific influences, -particularly strain and alcohol. Of its position as the principal -cause of grave disease of the valves as distinguished from the walls -of the heart, originating in middle life, there can be no question. -No fewer than nine out of 28 cases, of which I have private notes, -were the subjects of double aortic disease; practically all the -others had a loud ringing second sound over the aorta, significant -of degeneration; pain of anginal type in half the cases was the -prominent complaint; and two-thirds of the subjects had sclerosis -of the radial artery. When we consider that syphilis does also -affect the myocardium primarily; that fibroid disease, chronic -aneurysm and fatty degeneration of the heart are all traceable to -specific disease of the coronaries in many instances; and, finally, -that many of the subjects of syphilitic cardio-vascular disease -have perished before 40, the magnitude of this cause can be fully -realised. I believe that the profession in general have not yet -woke up, if I may say so, to the gravity of this subject. How -seldom we inquire for a history of specific disease in patients -coming to us with cardiac disease in middle life! To no one, as -far as my reading goes, are we so much indebted for the truth on -this subject as to my friend and colleague Dr. Mott. Thirteen -years ago he published a paper on 21 cases of sudden death from -cardio-vascular disease, and in nine of these there was a history of -either actual or probable syphilis. What was of greater interest, -however, at that early date, he drew attention to the association -of syphilitic cardio-vascular lesions with Bright's disease in the -broad acceptation of the term. Dr. Mott's work in the interval on -syphilitic lesions of the arterial system of the brain has been so -brilliant, and is so generally known, that it requires nothing more -than this appreciative mention by me, and it saves me the trouble of -an excursion into the subjects of cerebral haemorrhage and thrombosis -in connection with these lectures. - - -NERVOUS STRAIN. - -I confess that it is difficult to say much that is of real -diagnostic value on the clinical aspect of cardio-vascular disorders -and disease from nervous strain. As I remarked in discussing this -subject from the etiological point of view, several factors come -into play besides nervous excitement followed by exhaustion and -their effects on the heart, great vessels and cerebral arteries; -and the cases, therefore, are found to present a puzzling variety -of features. Certain clinical characters are, however, common to -the majority. Arterial tension is high; the radial artery is thick, -sometimes markedly so; the heart enlarges; and in about one-half of -the cases a systolic murmur is to be heard either in the aortic or -in the mitral area, significant of chronic endocardial lesions--all -readily intelligible results of cerebral strain in the light of -our knowledge of the innervation of the cardio-vascular system. I -have already pointed out that in some of these patients polyuria -and temporary albuminuria occur along with the high tension and -the increased action of the heart; but the heart may fail later -on. The direct cardiac symptoms of which they complain are of the -ordinary character, palpitation with accelerated cardiac frequency -and pain (not angina) being the most common at first, feelings of -indescribable discomfort and suffocation in the more advanced stage. -A great deal that I might have had to say on the very interesting -subjects of pseudo-angina, and the climacteric and pre-climacteric -disturbances of the circulation in women, I am reluctantly compelled -to omit from want of time. - - * * * * * - -After having reviewed, as I have attempted to do, the principal -clinical characters of the disorders and diseases of middle and -advanced life under their several causes, it may appear for a -moment strange that the most important of all the clinical types of -cardio-vascular degeneration has been mentioned only incidentally. -This is chronic Bright's disease, which, from its complex -pathological relations, its widespread effects on the heart and -circulation and the organs that they supply, and the far greater -gravity of these than those of any of the other causes which we have -studied (unless it be syphilis), is a subject of endless interest to -us all. Fortunately for me my immediate predecessor in this chair on -the medical side, our distinguished Fellow, Dr. Samuel West, took -for his subject the "Clinical Aspects of Granular Kidney," and thus -relieved me of a task which he was so much better able to discharge -than I. Emphysema must also be passed over with the single remark -that it is a very common accompaniment both of vascular and cardiac -degenerations. - -I trust you do not conclude that the description which I have just -given you of the clinical characters of these various disorders and -diseases of the heart is in any sense complete. It only relates to -the most prominent symptoms and signs as they present themselves to -us in what might be called the every-day life of the patient, at a -period in the history of his case precedent to failure. In all of -them there may occur occasional attacks of acute embarrassment of -the heart and lungs from one or more of a variety of causes, such -as indigestion, excitement or over-exertion. Sooner or later, also, -there occurs either cardiac dropsy--insidiously developed after -increasing local distress, growing dyspnoea and "bad nights"; or -Bright's disease; or cerebral thrombosis or haemorrhage, or acute -myocardial failure with angina: or the patient dies from failure of -the heart in the course of some acute disease such as bronchitis or -pneumonia. Neither have I considered it necessary in this lecture to -dwell on some of the rarer phenomena occasionally met with, such as -tachycardia and bradycardia. I may have occasion to refer to them -next time in connection with prognosis. - - - - -LECTURE III. - - -MR. VICE-PRESIDENT AND GENTLEMEN,--In this, the concluding lecture -of the series, I will attempt to deal with the applications of -the facts and considerations which I submitted to you on the two -previous occasions when I had the honour to address you. I trust -that what I then laid before you proved to be of some interest. -Let us see now whether it is practically useful. However much the -etiology and pathology of the diseases and disorders of the heart -and arteries in middle and advanced life may deserve study as -matters of natural history, we should be disappointed if they could -not be turned to account in prognosis and treatment. These are the -subjects I propose to discuss this evening. - -Now, prognosis and treatment, to be rational and useful, have to be -based on as full and as correct a diagnosis as knowledge permits. -The present disposition is to fall short of this; to rest content -with an incomplete diagnosis. We say that the patient's "heart -is dilated," that he has "arterial degeneration," that there is -"fatty degeneration." But you will remember that we have found that -cardiac dilatation may be present in every kind of cardio-vascular -degeneration; that the arteries are naturally enlarged and thickened -after middle life, and that we refused to call these changes morbid. -Clearly, therefore, a purely anatomical diagnosis of this sort -is insufficient. If you are asked what the prognosis is of fatty -degeneration of the heart, you answer that you must first be told -whether syphilitic or gouty disease of the coronary arteries, or -strain, or alcoholism, or phosphorus-poisoning or anaemia is the -cause of it. When you are planning the treatment of dilatation of -the heart you first determine whether the dilatation is a result -of the stretching of a sound heart by overfilling during muscular -effort, or of the insufficient emptying of failing chambers with -degenerated and feeble walls. Obviously what we ought to determine -in these instances and in every instance is the origin of the -disease. The ultimate diagnosis to be reached for practical purposes -is the etiological diagnosis. - -Is this possible? Does our knowledge of the nature, characters and -course of these cardio-vascular affections enable us to say, after -investigating a case, what the kind of the pathological change is -that constitutes the disease, or in what respect the physiological -mechanisms are disordered? Can the cause of these degenerations of -the heart and arteries be determined in each instance? How is the -practitioner to proceed to do so? What method might be followed with -advantage in making a complete diagnosis of heart disease in older -subjects? - -A man of 60 consults us about his heart. He says that it has caused -him a good deal of concern lately. More specifically he describes -a sense of oppression behind the sternum as often as he exerts -himself, and palpitation with consciousness of irregular cardiac -action when he goes to bed. We inquire for other familiar cardiac -symptoms, such as pain, angina, fluttering, faintness, giddiness, -and a sense of impending death. We find that one or more are present -occasionally, and that they have increased in number and degree -during the last few months or years. Perhaps cough, nocturnal -orthopnoea and dropsy may be beginning to give trouble. The next -part of the inquiry relates to the patient's previous history -from childhood upwards. Which of the acute diseases has he had? -Acute rheumatism, chorea, scarlet fever, typhoid, diphtheria and -influenza must be mentioned individually, and in women the nature -of any puerperal disease from which they may have suffered. Gout, -irregular gout, gravel, eczema, sick headache, asthma must be -inquired after with the same minuteness, and so must syphilis. We -next hear an account of any accident which the patient may have met -with, such as a blow, or a fall from a horse or a carriage. This -brings us naturally to question him about his occupation and modes -of relaxation and amusements--whether active or sedentary, regular -or irregular, their characters otherwise, and their direct effects, -including strain. More difficult to elicit is a correct account of -the patient's habits--in respect of food, stimulants and tobacco, -and his manner of life generally. As I said in my first lecture, -this is an inquiry which the family practitioner has an opportunity -to carry out much more successfully than the hospital physician -or consultant. The family practitioner has known for years of his -cardiac patient's work and worries; it may be of his large eating, -of his secret drinking, of the history of syphilis in earlier years. -It is always well also to inquire after a family history of gout, -rheumatism and heart disease. A list of questions like this sounds -far more formidable than it is in reality. A few minutes suffice to -arrive at the truth. We already have a pretty fair notion what we -have to deal with, whether strain, gout, syphilis, tobacco, an old -rheumatic lesion, or a combination of two or more of these. - -We next proceed to physical examination, beginning with the pulse -and arteries, and passing on to the heart and associated structures. -The characters of the praecordial impulse--particularly the seat -of the apex-beat and the strength of the impulse--are closely (I -might almost say laboriously) investigated. We must never yield to -the temptation to disregard weakness or absence of the impulse. -Like many other negative signs it is apt to be overlooked. Then the -praecordial dulness is mapped out by means of light percussion. -Finally, auscultation reveals to us the presence or absence of -murmurs and the characters of the sounds--in the standing and -recumbent postures, and, if necessary, after a little exertion. The -relative loudness of the first and second sounds over the different -parts of the praecordia is particularly worthy of note. - -Now let us suppose that we have found a mitral systolic murmur. We -ask ourselves whether it is structural or whether it is functional, -that is, due to relaxation and dilatation of the ventricular walls. -If structural, with which (if any) of the diseases elicited in the -man's previous history would it correspond? Most probably with -gout or glycosuria. Thus we attempt to connect the lesion with -its cause, and the cause with its effects, and have reached the -ultimate diagnosis. So with other valvular murmurs: for example, -an aortic diastolic murmur proves to be related to syphilis. If -there be no murmur audible, we naturally think of dilatation with -failure, or of enlargement from strain, from Bright's disease, from -arterial sclerosis, from emphysema, from an insufficient or impure -blood-supply in the coronary arteries, from disordered innervation, -or from some rarer cause, such as adherent pericardium; and then, -with these associations in our minds, we review once more the -patient's history, and generally succeed in our diagnosis. - -Here let me recount the significance of the principal signs and -symptoms which I detailed to you in my last lecture, considered in -the reverse order on this occasion, some of which are of real value -in differentiating the causes of cardio-vascular degeneration. To -begin with negative facts: a mitral pre-systolic murmur is never -significant of a degenerative lesion. Secondly, when we meet with -an aortic diastolic murmur, whether alone or along with an aortic -systolic murmur, we may safely conclude that we have to deal with -something more than atheroma produced by regular or irregular gout -and associated metabolic disturbance, cardio-vascular disease of -nervous origin and alcoholic or tobacco heart, even if there be -evidence of the presence of one or more of these in the case. -Aortic incompetence developed in later life is the result of -syphilis, or of acute or chronic valvular strain; but, of course, -many instances of this lesion met with after the age of 40 can -be traced to juvenile endocarditis of rheumatic or other origin. -Always a serious lesion, aortic incompetence due to syphilis, or to -syphilis and strain, is particularly grave, as being so frequently -associated with coronary disease and consequent myocardial -degeneration--fatty or fibroid, acute softening, and sudden fatal -failure. A fully-developed basic systolic murmur, audible over the -aortic area and manubrium and along the course of the carotid, -is a very common sign of atheroma of the aortic arch and valves -and great vessels in association with regular or irregular gout, -diabetes, corpulence and allied disorders of nutrition. It is also -one of the physical signs of syphilitic and traumatic affections of -the aorta and aortic valves and of remote endocarditis. Further, -these lesions are so often accompanied by similar degenerations in -the coronary arteries and consequent myocardial degeneration, that -the basic systolic murmur ought at least to raise the suspicion -of this in the observer's mind. An ill-developed basic systolic -murmur is not uncommon in alcoholism, chronic Bright's disease and -nervous strain, but it is difficult to dissociate from anaemia. A -fully-developed systolic murmur audible in the mitral area, I mean -independently of ventriculo-auricular leakage in cardiac failure, -is usually traceable to early endocarditis of rheumatic or other -origin, rarely to injury, including ordinary juvenile strain of the -valves or walls, or to Graves's disease. But in some instances it -is unquestionably due to valvular atheroma and attendant sclerosis, -caused by gout or other disturbances of metabolism, including the -effects of free living; and in these instances the observer must -not overlook the possible association of coronary disease and fatty -degeneration. If a systolic mitral murmur prove to be somewhat -indefinite and affected by posture, cubitus and effort, to vary -under observation from day to day, and to disappear under treatment, -it is of no more value to us in differential diagnosis than that -it signifies relaxation and weakness, or disorderly action, of the -left ventricle, consequent on any one of the recognised causes of -failure or disturbance of the heart, including the different cardiac -poisons, overwork, anaemia, acute disease, poverty and the like, and -this whether in a heart previously sound or previously enlarged or -previously the seat of valvular disease. An accentuated ringing -second sound in the aortic area, or more extensively, is of great -value in the diagnosis of arterial tension and of aortic atheroma or -of both, but it is associated with far too many different causes to -be of much use in differential diagnosis. It should suggest a most -careful search for Bright's disease. Slight reduplication of the -first sound is common over the heart strained in youth and the heart -degenerated by alcoholism and metabolic disorders, but everyone -knows that it is not unusual in a variety of other conditions, -healthy and morbid. On the other hand, the _bruit de galop_, or -cantering rhythm of cardiac sounds--definite doubling of the first -sound followed by loud, accentuated, ringing second sound--is -practically pathognomonic of Bright's disease, and is one of the -most valuable, because one of the most ominous, of physical signs in -connection with the cardio-vascular system. A normally-sized heart -with irregularity, increased frequency, and a variable systolic -murmur in the mitral area, is characteristic of tobacco poisoning. A -heart enlarged on both sides, and acting irregularly without murmur, -is (apart from cardiac failure) suggestive of strain in early life. - -Cardiac symptoms taken individually are of less diagnostic value -than signs. No symptom is pathognomonic. Palpitation is a nearly -universal phenomenon of cardiac disease and disorder. Faintness and -actual faints are not uncommon in cases of early cardiac strain, -gouty heart, and nervous disturbances. Angina we meet with, you -will remember, in regular and irregular gout, tobacco heart, strain -(especially strain after 40), and in syphilis and alcoholism, -whilst pseudo-angina is extremely common in nervous women: thus -angina is of less diagnostic value than might have been expected. -A high-tension pulse I have found most often in Bright's disease, -in juvenile strain, and in cardio-vascular affections of nervous -origin; a low tension pulse in connection with alcoholic and tobacco -poisoning, and with senile strain. - -When we review these facts, I think we are entitled to conclude that -the physical signs and symptoms carefully determined by clinical -investigation may be confidently employed, along with the patient's -previous personal history, and the history of his present illness, -to differentiate from each other the causes of cardio-vascular -degeneration in individual cases. And, further, that they inform -us of the seat of at least some of the lesions, valvular, parietal -and vascular. A little trouble, patience and attentive observation -are all that are required to reach a complete or working diagnosis. -Now we may approach the great practical subjects of prognosis and -treatment with some confidence. - - -PROGNOSIS. - -Beginning with the simplest kind of cardio-vascular disorder, let us -see what the prognosis is in tobacco heart. You will have gathered -from what I had to say on this subject in my last lecture, and -indeed you know as men of observation and experience, that it is -comparatively favourable. All the cases I have had an opportunity to -watch did well, provided the cause of their distress was avoided and -the heart and vessels were otherwise healthy. Further, improvement -begins early, and it may be rapid and recovery complete; but you -will remember that one patient, whose case I detailed to you, -continued to have alarming angina for six months after giving up -tobacco. Recurrence attends resumption of the habit, but some of -its votaries contrive to continue to smoke just short of inducing -serious discomfort. Unless a successful effort at reform be made, -cardiac trouble may continue indefinitely. But even then I cannot -say that I have seen serious damage done by tobacco alone in -sound hearts, nor arterial sclerosis, as has been stated by some -authorities. - -An entirely different and most unfavourable estimate is to be formed -of the prospect of life in the alcoholic heart. Naturally, a certain -proportion of cases recover if the disease be of recent development, -the condition uncomplicated, and treatment faithfully carried -out. Unfortunately, as a rule, we have to deal with alcoholism in -which all these conditions of success are wanting. The habit is -established, other organs besides the heart are involved, other -diseases than alcoholism are present, and the patient has neither -the inclination nor the power to follow our advice. Cirrhosis, -neuritis, dementia complicate the cardiac degeneration, or, more -correctly, it complicates one or all of these. Chronic Bright's -disease is made to account for a number of deaths in the mortality -returns that strictly belong to alcoholism. Occasionally the end -comes suddenly from fatty degeneration, or in the course of some -acute disease; otherwise, as we have seen, by slow cardiac failure -and dropsy. - -Prognosis in gouty heart, including the heart of the man with -goutiness, glycosuria and other irregular forms of the disease, is -a subject of considerable practical difficulty. In my last lecture -I read to you a short account of the case of a friend of my own -who had had occasional attacks of gouty angina for 40 years. And -certainly a large proportion of the old ladies of 60 or 70, whom -you all have had as patients for years on end with weak heart -and systolic murmur in the aortic area, owe their disablement -to gout, if my observations are correct. The lesion proper of -the aorta and aortic valves in these cases is atheroma, but the -damage is accompanied with repair in the form of sclerosis, which, -by increasing the loudness of the bruit, adds unreasonably to -our anxiety about the case. Equally certain it is that patients -belonging to this class improve under treatment. Still, the -condition of arrest cannot go on indefinitely. In addition to -extrinsic dangers, particularly those of Bright's disease, cerebral -thrombosis and haemorrhage, and bronchitis, failure of the heart -is liable to supervene and prove fatal from the gravest of all -intrinsic causes, namely, coronary degeneration. As this increases, -the myocardium is steadily more and more impoverished; its -contractile vigour declines, and residual dilatation of the chambers -sets in with mechanical congestion of the viscera. Complaints of -"the heart" increase, the breathing becomes oppressed, the face -assumes more and more the characteristic "cardiac" appearance, and -dropsy creeps up the lower limbs. Even then the prognosis is not -hopeless, for undoubtedly a certain proportion of cases of dropsy in -old persons with degenerated heart and vessels are still amenable to -rational treatment. But the case has occasionally a more dramatic -termination. As I was able to illustrate after my second lecture by -a specimen from the Museum of Charing Cross Hospital, a branch of -one of the coronary arteries that has been narrowed by atheroma for -an indefinite length of time, with consequent cardiac weakness and -discomfort, may any moment become thrombosed rapidly, apparently -in consequence of some passing depression or other unfavourable -influence, just as in thrombosis of degenerated cerebral vessels. -Fatal angina is the result. This is a point of great practical -importance--that sudden death will occur in old gouty subjects not -from the lesion of which a basic or an apical systolic murmur is the -evidence and which causes us concern, but from associated coronary -atheroma, which we probably never suspect; indeed, that it may occur -in those subjects with no murmur whatsoever to attract our attention -and excite our fears. - -Still more unfavourable must be the forecast in syphilitic lesions -of the heart and vessels. Of 18 of my cases in which the result was -known, only one-half improved under treatment, and 20 per cent. of -them died within a few years (some indeed within a few weeks) of the -discovery of their disease. Cardiac failure accounts for most of the -deaths, whether developed gradually with dropsy, which proves to be -intractable; or progressing rapidly with great cardiac distress, -including angina; or occurring suddenly, as it often does. Aneurysm -makes its appearance in other instances, of which the patient dies, -or he is carried off by general paralysis or Bright's disease. - -What prospect have we to hold out to the man who has strained the -walls of his heart by muscular effort? I believe that one can speak -with some confidence on this subject. The middle-aged patient who -over-stretched his cardiac walls as a youth may be comforted with -the opinion that the condition is not a fatal one. The average -duration of 11 cases of this order I found to have been 30 years -when they came under my observation; the minimum duration was nine -years, the maximum 50 years. This last case deserves particular -mention. The patient was first seen by me for failure of the heart -with cardiac dropsy, consequent on fresh breakdown after exertion -during a holiday; and it is most encouraging to observe that -compensation was restored by treatment, and that now, 12 months -after that event, he is not only alive, but able to carry on light -professional work. This case also illustrates what I have told you -respecting the course of the affection, and the prospect before the -patients, in long-standing strain--that there is continual liability -to fresh embarrassment of the heart during exertion, in which they -appear to have a lasting inclination to indulge. If they happen -to follow an occupation that entails occasional effort, or effort -with excitement and worry (if they happen, let us say, to be busy -practitioners of medicine), they suffer in the same way from attacks -of tachycardia, distressing palpitation and anxiety. Indeed, as I -pointed out in my second lecture, they are readily upset by other -influences besides these, including indigestion, to which the victim -of hurry and worry is peculiarly liable; and they must be prepared -to have to lead a life of comparative temperance and self-denial. - -Neither is strain of the heart for the first time after 40 by any -means so grave as might be expected. Of course, sudden muscular -effort occasionally accounts for sudden death in old men. But it -is astonishing how, under such circumstances, quite old persons do -recover from conditions of extreme distress lasting acutely for -half an hour--for instance, after running with a heavy bag to catch -a train. The majority of my patients described their condition as -improved after a time, but others relapsed; and on the whole the -correct prognosis is that they must expect to remain variously -disabled--that is, liable to praecordial distress and dyspnoea on -more than moderate exertion, or when subjected to circumstances of -other kinds that tax the heart. - -Cardio-vascular disorder and disease referable to nervous strain -pure and simple is amenable to treatment by complete and prolonged -rest or relaxation in the majority of instances. Still, death may -occur from sudden cardiac failure; or should advice be neglected -or soon forgotten, as happens so frequently in these subjects, -the attendant high arterial tension and vascular degeneration too -often end in cerebral lesions, with or without Bright's disease. Of -chronic Bright's disease itself and the associated cardio-vascular -changes in their prognostic aspects I need not speak, except to say -that along with syphilis it is by far the most hopeless of all these -affections. - -In attempting to forecast the life of a man who is the subject of -cardio-vascular degeneration in middle or advanced life, we must -not forget the possibility of the intercurrence of acute disease. -Here is a large subject for us as practical men--one far too large -and important for discussion here: the effect, for instance, of the -existence of enlargement of the heart and an irregular and thickened -pulse on the prognosis of influenza, or, let us say, on the chances -of a successful issue after operation. Very naturally, unsound -vessels and a murmur over the praecordia weigh heavily against the -prospect of recovery from pneumonia, for example; and yet how often -do we not find a patient of 70 with one or both of these disturbing -conditions come safely through such an illness! Here, again, I -believe it is in great measure the true nature of the old-standing -disease, not the physical signs such as irregularity of pulse or -mitral bruit, that ought to be taken into account. A heart enlarged -and a radial artery thickened by prolonged activity and nothing else -will suffice to carry a man safely through an attack of influenzal -pneumonia; but what chance is there for the chronic alcoholic under -similar circumstances, or for the subject of chronic Bright's -disease? - -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, praecordial -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 praecordial 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. - - [15] G. W. Balfour, 'The Senile Heart,' p. 236, 1894. - -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 toxaemia and anaemia; 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 haematinics, 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 praecordial 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, dyspnoea 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 praecordial 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 anaemia -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 praecordial 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 71/2 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 - - - - - -End of the Project Gutenberg EBook of The Lettsomian Lectures 1900-1901, by -J. 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