by no means so easily determined as those of tobacco. In the first
place, they are complicated with the many indirect effects which it
produces on these organs by deranging the functions of alimentation
and assimilation, the nervous system and the kidneys, and with the
secondary effects on the vessels and heart of chronic nephritis
due to the same cause. In the second place, as we saw in my first
lecture, alcoholism is very commonly associated with nervous strain,
with gout and goutiness, with tobacco, with syphilis, and not
uncommonly with two, or more, or all of these together. Eliminating
as far as possible these sources of error by careful selection of
cases, I find that the alcoholic heart in middle and advanced life
presents clinical characters, as a whole, very different from those
of tobacco heart, which we have just studied. The most striking and
important of these are the evidences of actual pathological change
in the size of the heart and the condition of the myocardium. We
found no evidence that tobacco causes serious cardiac enlargement,
and neither may alcohol in quite young subjects, who present mainly
excited action both in force and in frequency. But of 28 cases of
alcoholic heart which I examined clinically in connection with the
present inquiry in older subjects, only two hearts were of ordinary
size (and as a matter of fact both of these patients were under
40 years of age). This result is in accord with my pathological
observations. For instance, I have carefully followed the condition
of the heart in an intemperate man of 43, and _post mortem_ found
the heart to weigh 17 ounces, to be universally dilated in all
its chambers, and to present enlargement of the mitral opening
without valvular lesion, corresponding with a weak apex systolic
murmur heard during life. These results are also in accord with
those in Dr. Maguire's cases of acute dilatation of the heart from
alcoholism, which he recorded as long ago as 1888[7] (when, I may
add, doubts were expressed of the correctness of his conclusions
by several of our best authorities on cardiac disease), and one of
which occurred in a man of 23. Dr. Mott has found fatty degeneration
of the myocardium in patients dying suddenly during alcoholism.[8]
With hardly an exception the præcordial impulse is weak--indeed,
it is often imperceptible; the sounds are small and feeble, and
may be almost inaudible; in 20 per cent. of my cases a weak apex
systolic murmur could be heard, varying with posture and from day
to day, significant, no doubt, of leakage through a dilated mitral
opening. The alcoholic heart is irregular and accelerated in about
half the cases. The pulse tension is usually low; in one-third of
the instances the radial artery was sclerosed; in one-fifth of them
there was slight albuminuria; the legs may be 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.
[7] Maguire, 'Trans. Clin. Soc. of London,' vol. xx, p. 235.
[8] Mott, "Cardio-Vascular Nutrition and its Relation to Sudden
Death," _Practitioner_, xli, p. 161.
The course of alcoholic heart in older subjects usually becomes
affected by the appearance of cirrhosis of the liver, Bright's
disease, neuritis, and possibly dementia. The method of termination
is very various, including ordinary cardiac failure with dropsy;
and sudden death occasionally occurs. Still, recovery is far from
being impossible, even after dropsy has made its appearance, for
the size of the heart may decline under strict abstinence from
alcohol, and the 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] just as there are
changes in the pyramidal cells and fibres of the cerebral cortex in
the alcoholic; and the feebleness and irregularity of the heart are
analogues of the depression and confusion of the brain.
[9] Mott, 'The Croonian Lectures on the Degeneration of the
Neurone,' p. 110, 1900.
GOUT.
Of the many instances of disorder and disease of the heart and
arteries that I have met with in gouty subjects at or over 40 years
of age, I have made a careful study of 29 taken from my private
case-books. Twelve of these (10 M. + 2 F.) had suffered from
ordinary articular gout, the other 17 (6 M. + 11 F.) had irregular
gout, as defined in my first lecture. The average age was 62. In
no instance was there albuminuria. The physical condition of the
heart and arteries and the patient's complaints were remarkably
alike in the two groups. In 23 of the 29 the heart proved to be
enlarged, either on one or both sides. In less than half the number
the cardiac action was feeble; in a small number the impulse was
entirely imperceptible; the heart- and pulse- rate was ordinary; the
rhythm was but seldom irregular. It is a very remarkable fact that
in no fewer than 12 out of the 29 cases of gouty heart a systolic
murmur was to be heard over the aortic area, the manubrium and the
right carotid, significant of disease either of the aortic arch or
of the aortic valves--in every instance independently of rheumatism
or other obvious cause than gout. This result is an interesting
confirmation of the pathological observations of Dr. Norman Moore
and Sir Dyce Duckworth given by the latter,[10] and of the statement
of Murchison[11] of his experience "that atheroma of the arteries
at an unusually early period of life, and diseases of the aortic
valves which are not congenital, and are independent of injury
or rheumatism, are met with far oftener in persons who are the
subjects of the lithic acid dyscrasia, or who have had gout, than
in those who have had no such tendencies." In seven (25 per cent.)
of my cases a more or less developed systolic murmur was found
in the mitral area, significant either of valvular atheroma and
sclerosis or of leakage from ventricular dilatation. Very curiously
I have never met with aortic incompetence of gouty origin. When no
murmur exists the cardiac sounds are commonly somewhat feeble, and
the second sound may be of ringing quality--this more commonly in
goutiness than in developed gout. In agreement with this connection,
the radial pulse is more often tense in the subjects of irregular
than of regular gout[12]; altogether, high tension is found in more
than one-half of the cases. The great majority presented distinct
thickening of the arterial walls. As I suggested in our study of
the etiology, these pathological changes appear to be the result of
malnutrition of structures (the myocardium, valves and arteries)
worked at high pressure; and in addition to the local disturbance
of metabolism in the cardiac and arterial walls, which are fed with
gouty blood, there is the damaging effect on them of similar disease
of the _vasa vasorum_ and _vasa cordis_ or coronaries.[13] Besides
a distressing feeling of irregularity, fluttering or intermittency,
and 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.
[10] Dyce Duckworth, 'A Treatise on Gout,' 1889, p. 108.
[11] Murchison, 'Clinical Lectures on Diseases of the Liver,' 3rd
edition, 1885, p. 637.
[12] _Cf._ Clifford Allbutt, "Selections from the Lane Lectures,"
_Philadelphia Med. Journ._, January 27th, 1900.
[13] Mott, _Practitioner_, _loc. cit._, p. 169.
OBESITY AND GLYCOSURIA.
Closely related to goutiness is a clinical type of disturbed
metabolism, mainly characterised by corpulence, a bulky, flabby
build, and glycosuria. Of this type, represented by 12 cases in my
series, nine had glycosuria and two albuminuria; eight were men; the
average age was 58. Only one had suffered from true articular gout.
Here, again, the interesting observation was made that no less than
three-fourths of the number had a systolic aortic murmur, none of
them a regurgitant aortic murmur, and nearly one-half of them an
ill-developed mitral systolic murmur. Thus there appears to be more
liability to atheroma in the gross corpulent diabetic even than in
the gouty man. In all the cases the heart appeared to be enlarged,
but accurate physical examination is difficult or impossible in
many of these subjects. The impulse was more often feeble than in
the gouty; the cardiac sounds were equally weak, and the second
aortic sound was occasionally accentuated. The pulse corresponded
with the gouty pulse in thickness and tension, but it was more often
found irregular and hurried. As for the complaints of corpulent and
diabetic patients, they prove to be very similar to those of gouty
individuals in respect of pain, but neither palpitation, faintness
nor irregularity was so often mentioned.
It must not be understood from what I have just said in my account
of these cases that all disturbances of the heart in gouty subjects
progress to valvular or vascular degeneration, with associated
cardiac enlargement and degeneration. The friend whose case I have
just described at some length had led an active life, as I said, for
40 years; and, as I hope to show in my next lecture, the condition
is amenable to treatment if this is based on a correct appreciation
of the cause that is at work. But it is equally true that if correct
advice be not given, or if it be given but be neglected, as happens
so frequently, the endocardium and the aorta and other arteries
steadily degenerate, chronic interstitial nephritis makes its
appearance, and the patient dies either slowly from cardiac failure
or suddenly from cerebral hæmorrhage.
CARDIAC STRAIN.
I will now proceed to consider the clinical characters of a class
of cases in which you, Sir, are particularly interested--strain
of the heart in middle and advanced life. To make this part of my
subject more plain, I will discuss in the first place acute strain
of the heart as it occurs after the fortieth year; afterwards I will
consider the condition of the heart and arteries at this age in
persons who have strained them in youth or early manhood.
A man of 65, who came to me complaining of his heart, gave the
following account of the commencement of his trouble:--Four years
previously, on making a very hard stroke at golf (the ball was
bunkered), he was suddenly seized with a sensation of something
having happened in his heart. He played up to the next hole, but
now felt the chest oppressed; he sat down and got relief. This
experience was repeated, and he gave up the round. Walking home
two miles, he had to sit down occasionally with the same feeling.
Ever since that occurrence exertion had produced the same effect.
I found the ordinary physical signs of enlargement of both sides
of the heart; a scarcely perceptible impulse; the cardiac sounds
extremely feeble, the second being of a finely ringing quality; the
pulse tense, quiet and regular, but the radial artery by no means
sclerosed. The patient's principal complaints were of irregular
action of the heart, which troubled him on lying down or when he
was dyspeptic; and, as I have said, of post-sternal oppression on
exertion. This man had neither albuminuria nor emphysema, but he
had frequently suffered from ordinary articular gout. Belonging
to this type of cardiac strain I have notes in all of 11 cases,
which I will briefly summarise. Eight were men, three women; and
their average age was 56. In all but one of them the heart was
large, with feeble præcordial impulse; the sounds were small and
feeble; the aortic diastolic sound was often ringing; in but one
case was there a murmur--aortic systolic; with few exceptions the
rhythm and the rate of the heart were ordinary. In half the cases
the radial artery was sclerosed; in the majority the tension was
not increased. Persons who strain their heart after middle life
chiefly complain of præcordial oppression, 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] It might be contended with great reason that
exertion in these subjects is not a cause of strain or dilatation of
the heart, but simply a test, as it were, or the proof, of cardiac
debility and disability. But when we come to consider cardiac strain
a little more closely, it may be just as easily maintained that
every dilated heart, every dilated cardiac chamber, every dilated
blood-vessel has been strained. Whether, on the one hand, valvular
disease, Bright's disease or emphysema, or, on the other hand,
myocardial degeneration, has disturbed that cardinal condition of
a normal circulation that the driving power must always exceed the
resistance ahead, over-distension and dilatation of the cavities,
with excessive stretching of their walls, constitute or consist in
mechanical strain. However, laying aside theoretical discussions
of this character, the great practical fact remains, that when the
aged and ill-nourished heart is over-distended from sudden and
severe exertion, neither the elastic nor the muscular tissues of
its walls can bear the strain; it becomes dilated; for the future it
acts at a mechanical disadvantage; and as often as this may occur
it suffers still more in its efficiency. On the other hand, it is
really in confirmation of this consideration, though apparently in
opposition to it, that the heart may diminish somewhat in size, and
præcordial distress disappear, under strict treatment continued for
a sufficient length of time.
[14] Clifford Allbutt, 'System of Medicine,' v, p. 843.
STRAIN BEFORE FORTY.
A more interesting group of cases than those which I have just
discussed is composed of persons who have strained their hearts in
youth or early manhood, have never been quite well since, and in
middle or advanced life are at last driven to us for help. Cases
of this character would furnish excellent material from which we
might attempt to judge of the after-effects of excess or abuse
of muscular exercise in the young. This is a tempting subject of
discussion, but one far too long and much too important to be taken
up casually at this time. Therefore, I will content myself with
submitting to you as plainly as I can certain facts bearing on it
that have come before me in my present inquiry, along with a few
simple observations of a practical bearing. First, then, let me
read to you the history of what I should call a typical case of the
kind. A man of 69 complains that as often as he walks any distance
or climbs a stair he is arrested by a distressing sense of having a
bar across the lower end of the sternum, breathlessness, irregular
palpitation of the heart, and a very little choking in the throat;
the discomfort has lately deserved the name of pain. His heart is
very large, the area of præcordial dulness being increased in all
directions and measuring transversely 7 inches. The impulse is
weak over the left ventricle, but definite in the epigastrium; the
sounds come in couples--moderately good and very weak respectively,
without murmur; and the radial artery is large and thick, with
rather low pressure and irregular rhythm. It turns out that for the
last 40 years these uncomfortable feelings have troubled the man
more or less, and that at three different periods of his life--at
31, at 42 and at 67--they increased so much as to incapacitate him
for many months, the first time with a sudden sense of something
snapping in the heart, the second time with a faint, and always,
as he believes, consequent on overwork. Now this man never had
rheumatism, nor gout, nor syphilis, and was always a temperate,
careful liver; and he volunteers the statement that he first felt
his heart at Cambridge, where he was captain of his College boat,
and was tried for the University boat but felt that he was not fit
for it. Belonging to this type of cardiac strain I have selected
11 cases. The heart is always found to be enlarged, and in about
one-half of the cases it is irregular. It may be weak and beating
at the ordinary rate, but in other instances it is increased both
in force and frequency. Only in quite exceptional cases did I meet
with endocardial murmurs in this group of old strained hearts; as a
rule the sounds were ordinary, with a disposition to accentuation of
the aortic second sound. High tension and sclerosis of the radial
artery were respectively found in about one-half of the cases. The
patients complain most commonly of a distressing sense of irregular
palpitation of the heart, and very commonly of præcordial pain,
but rarely of angina. Faintness also is sometimes mentioned. Let
me hasten to add, with respect to these cases, that they do not
include any instances of direct injury of the valves mechanically.
Rupture or stretching of the aortic and mitral valves during
exertion furnishes us with some very remarkable clinical cases; but
it is with parietal strain that we are concerned now--mechanical
over-stretching of the cardiac walls, which are thereafter left with
but a narrow margin of the elastic and muscular reserve required
by them to meet trying circumstances of any kind, particularly
exertion. The subjects of dilatation of the heart from mechanical
stress suffer by no means from what is commonly called "heart
disease," excepting in the worst cases, but yet they feel their
hearts comparatively, and it may be seriously, disabled. Naturally
they associate these feelings of disability with fresh attempts
at exercise or exertion, as in the case which I have just read. I
pointed out in my first lecture that such exertion is not by any
means connected with the patient's occupation or daily duties, but
quite often occurs during unwise attempts on his part to resume
at 50 the athletic exercises of his youth in order to reduce his
weight, relieve his liver, or dispel gout. It is not wonderful that
under such circumstances a permanently enlarged and badly-nourished
heart should become embarrassed, or even seriously deranged or
still further strained. I have known a man of 43, going straight
from London to the Alps, have not only præcordial distress but
dropsy of his legs after his first ascent in his regular holiday.
Indeed, the man who has reached later middle-life with his heart
enlarged by years of great bodily activity in youth, and settles
down quietly on retirement, let us say from the navy, sometimes
finds that ordinary exercise is sufficient to produce alarming
cardiac distress and curious loss of courage, obviously due to the
muscular tissue of the thickened cardiac walls having fallen quite
out of condition. How instructive, for instance, is the following
case:--A gentleman of 60, who has led from his boyhood upwards a
life of physical activity and at the same time of temperance, and
has suffered from neither syphilis nor rheumatism, but possibly from
a very mild attack of gout, settles in a relaxing provincial town,
continues to eat heartily, and considers that a little work in the
garden is sufficient exercise for him. He increases in weight, his
breath gets short, his heart flutters, and now he begins to get
anxious about his health, fancying, as he says, that he has all
sorts of diseases--a disposition to worry about himself which is
entirely new and provoking to him. I find his heart very large and
feeble, the cardiac sounds scarcely audible, and in the mitral area
a well-developed systolic murmur. The patient is ordered to reduce
his diet as a whole and in respect of carbo-hydrates, to return
carefully to walking exercise on the level, and to take a calomel
purge followed by a saline twice a week, and a mild strychnine
mixture. He improves, and continues to do so; is able to walk miles
without discomfort; and in the course of two months not only do
I find his heart reduced in size on physical examination, but I
fail to hear the apical murmur, which must have been produced by
dilatation of the left ventricle. The bearing of such a case as this
on the pathology, prevention and treatment of certain cases of heart
disease in old subjects will be obvious to all.
We must be careful, however, to observe that neither unwise
abandonment of wholesome exercise, nor ill-advised return to
physical exertion, separately or in succession, can be regarded
as the only cause of the recrudescence of cardiac distress after
40 in those who have strained their circulation in youth. Any one
of the many circumstances that produce cardiac failure and dropsy
in chronic valvular disease may lead to embarrassment and fresh
dilatation of the simply enlarged heart: anæmia and chronic disease,
the acute specific fevers including pneumonia, emphysema, granular
kidney, gout, syphilis, tobacco and alcohol poisoning, as well as
anxiety and worry, and in women the advent of the menopause; and I
may say here parenthetically that pains at the heart in athletic
youths are sometimes due to the tobacco smoking in which they
often indulge socially when the exercise is finished--not to strain
at all. In these cases of old cardiac strain, as in every form of
chronic valvular disease and of chronic heart disease of all kinds,
not only the original and permanent lesion, but the recent and
probably temporary circumstance that caused the failure has to be
ascertained and fully respected in connection with prognosis and
treatment.
SYPHILIS.