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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.

Maguire, 'Trans. Clin. Soc. of London,' vol. xx, p. 235.

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, 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.

Mott, 'The Croonian Lectures on the Degeneration of the Neurone,' p. 110, 1900.

GOUT.

Dyce Duckworth, 'A Treatise on Gout,' 1889, p. 108.

Murchison, 'Clinical Lectures on Diseases of the Liver,' 3rd edition, 1885, p. 637.

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 , 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. 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.

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 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.

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.

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 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 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.

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 , 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 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 , 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?

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 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 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." 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.

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.

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 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.

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 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.

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