The Lettsomian Lectures on Diseases and Disorders of the Heart and Arteries in Middle and Advanced Life [1900-1901]

The Lettsomian Lectures on Diseases and Disorders of the Heart and Arteries in Middle and Advanced Life [1900-1901]
John Bruce

The Lettsomian Lectures on Diseases and Disorders of the Heart and Arteries in Middle and Advanced Life [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 - 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 - Humphry, 'Old Age,' 1889, p. 23.] Even among the majority of centenarians the evidences of arterial degeneration were not manifest.[3 - Op. cit., p. 48.] 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.

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 - Humphry, 'Old Age,' 1889, p. 15.] 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.

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 - Leonard Hill, Allbutt's 'System of Me inc,' vol. xii; George Oliver, 'The Blood and Blood-Pressure,' p. 170, 1901.] 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.

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 - 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.] 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.

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 - Maguire, 'Trans. Clin. Soc. of London,' vol. xx, p. 235.] (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 - Mott, "Cardio-Vascular Nutrition and its Relation to Sudden Death," Practitioner, xli, p. 161.] 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 œdematous. 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 dyspnœa, 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.

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

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 - Dyce Duckworth, 'A Treatise on Gout,' 1889, p. 108.] and of the statement of Murchison[11 - Murchison, 'Clinical Lectures on Diseases of the Liver,' 3rd edition, 1885, p. 637.] 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 - Cf. Clifford Allbutt, "Selections from the Lane Lectures," Philadelphia Med. Journ., January 27th, 1900.]; 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 - Mott, Practitioner, loc. cit., p. 169.] Besides a distressing feeling of irregularity, fluttering or intermittency, and dyspnœa 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.

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, dyspnœa 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 - Clifford Allbutt, 'System of Medicine,' v, p. 843.] 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.

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.