Project Gutenberg's The Lettsomian Lectures 1900-1901, by J. Mitchell Bruce

This eBook is for the use of anyone anywhere at no cost and with
almost no restrictions whatsoever.  You may copy it, give it away or
re-use it under the terms of the Project Gutenberg License included
with this eBook or online at www.gutenberg.org


Title: The Lettsomian Lectures 1900-1901
       DISEASES AND DISORDERS OF THE HEART AND ARTERIES IN MIDDLE
       AND ADVANCED LIFE

Author: J. Mitchell Bruce

Release Date: September 21, 2013 [EBook #43780]

Language: English

Character set encoding: UTF-8

*** START OF THIS PROJECT GUTENBERG EBOOK THE LETTSOMIAN LECTURES 1900-1901 ***




Produced by Ian Deane, Julia Neufeld and the Online
Distributed Proofreading Team at http://www.pgdp.net







Transcriber's note:

Text enclosed by underscores is in italics (_italics_).

Small capital text has been replaced with all capitals.

Minor typographical errors have been corrected without note.
Irregularities and inconsistencies in the text have been retained as
printed.

       *       *       *       *       *




  HEART DISEASE

  IN

  MIDDLE AND ADVANCED AGE




  The Lettsomian Lectures

  ON

  DISEASES AND DISORDERS

  OF THE

  HEART AND ARTERIES

  IN

  MIDDLE AND ADVANCED LIFE

  _Delivered before the Medical Society of London, Session 1900-1_


  BY

  J. MITCHELL BRUCE, M.A., LL.D., M.D., F.R.C.P.,

  _Physician to Charing Cross Hospital; Consulting Physician to the
  Hospital for Consumption and Diseases of the Chest, Brompton_


  LONDON:
  HARRISON AND SONS, ST. MARTIN'S LANE
  PRINTERS IN ORDINARY TO HIS MAJESTY

  1902




  _To_

  JOHN H. MORGAN, C.V.O., M.A. Oxon., F.R.C.S. Eng.

  _President of the Medical Society of London, 1900-1901

  from his friend and colleague

  The Writer_




CONTENTS


  LECTURE I.
                                                            PAGE

  Introduction                                                 1

  Natural State of Heart and Arteries after 40                 3

  Causes of cardio-vascular disorder and disease               6

  Physical Stress                                              6

  Nervous Influences                                           8

  Cardiac Poisons                                              9

  Disturbances of Metabolism                                   9

  Gout                                                         9

  Syphilis                                                    10

  Acute specific fevers                                       11

  Chronic affections                                          11

  Complex causes                                              11

  Old-standing Rheumatic Lesions                              13

  Family heart                                                14


  LECTURE II.

  Clinical Characters and Course                              14

  Clinical Characters and Course of Tobacco Heart             15

  Clinical Characters and Course of the Heart in Alcoholism   18

  Clinical Characters and Course of the Heart in Gout         20

  Clinical Characters and Course of the Heart in Obesity
        and Glycosuria                                        22

  Clinical Characters and Course of Cardiac Strain            23

  Clinical Characters and Course of Cardiac Strain before 40  25

  Clinical Characters and Course of Syphilis of the Heart     28

  Clinical Characters and Course of cardio-vascular disease
        from Nervous Strain                                   29


  LECTURE III.

  Diagnosis, Prognosis and Treatment                          30

  Differential Diagnosis                                      31

  Value diagnostically of different physical signs            33

  Value diagnostically of different symptoms                  35

  Prognosis                                                   36

  Treatment                                                   37

  Conclusion                                                  50




THE LETTSOMIAN LECTURES

1900-1901




LECTURE I.


MR. PRESIDENT AND GENTLEMEN,--My first duty this evening is to
thank you, which I do most heartily and gratefully, for the
honour you have done me by selecting me to deliver the Lettsomian
Lectures for the present year. My second duty is to spend as little
time as possible on preliminary remarks, for--as you, Sir, know,
having yourself occupied this distinguished place on a former
occasion--three hours are all too brief for useful presentation of
material which one has collected for a purpose like the present. In
selecting the subject of my Lectures I was mindful of the character
and objects of this Society. In the Medical Society of London there
is a fuller blending of men engaged in family practice with men
holding hospital appointments than is the case at most of the other
learned societies connected with our profession in London; and
there is here an opportunity for free communication of experience
and interchange of opinion between these two classes of our Fellows
which cannot fail to be profitable to both. Therefore, I have taken
up a subject of thoroughly practical interest; and not only this,
but I will attempt to present it to you, to put you in a position
to look at it, from the point of view of the practitioner. The
problem of the diseases and disorders of the heart and arteries
in middle and advanced life may be said to come before the family
practitioner every hour of his work, and to offer difficulties and
create a sense of responsibility or even anxiety which are not
sufficiently appreciated by the hospital physician. There comes
before him the case of one of his patients, an active business
man of 45, who has been seized with angina pectoris when hurrying
to the station after breakfast, or that of an old friend, whose
proposal for an increase of his insurance at 50 has been declined
because of arterial degeneration and polyuria; or he is asked to
say whether a man of 60, occupying an important and possibly
distinguished position in the community, ought to retire from public
life because he has occasional attacks of præcordial oppression
and a systolic murmur at the base of his heart. What, again, is he
to do for the stout, free-living man, just passing the meridian of
life, who consults him for weakness and depression, whose heart is
large and feeble, and the urine saccharine and slightly albuminous?
There is not one of my audience who has not met with such cases as
these many times in his practice, and a variety of other cases of
cardiac disorder and disease after 40, where the importance of the
individuals, the value of their lives, and the gravity of their
complaints and their prospects have exercised him very anxiously.
What is the prognosis in cases of this order? What can be done for
them in the way of treatment? These are the questions which we
would desire to answer usefully. The answer, it seems to me, can be
given only after an analysis and study of a considerable number of
instances of the kind, in respect of their origin, their clinical
characters and course, and the result. This is the method of inquiry
which I propose to follow. It will be a study of cardio-vascular
disease in older subjects from the clinical point of view, and it
will be approached not only from the ordinary clinical side as
it is approached in hospitals, that is, by an investigation of
symptoms and signs, but also and especially in the light of that
particular order of knowledge which the family practitioner has
learned to appreciate and has so intimate an opportunity to acquire
correctly--a knowledge of the origin or causes of the different
affections, which it is always difficult, and often impossible, for
the hospital physician to ascertain. For the same reason, although,
to be complete, a study of the diseases of the circulation at and
after middle life should include an account of the _post-mortem_
characters found in fatal cases, and whilst the basis of the
account I submit to you will be essentially pathological, I shall
not attempt to describe the pathological anatomy and histology of
this group of lesions of the heart and arteries. This part of the
subject has been remarkably advanced during the last few years;
and even if I had the time and the necessary knowledge to deal
with it now, I should have nothing original in it to lay before
you. Indeed, if I may venture to say so, our attention lately has
been too much confined to the pathological states of the heart and
arteries and too little directed to the causes which produce them.
"Arterial sclerosis" is now an ordinary diagnosis in every-day
practice, as if it were sufficient for purposes of prognosis and
treatment to have determined that the radial artery is thicker and
longer and more dense than normal, without regard to the actual
nature of the pathological change, whether strain, or syphilitic,
or gouty, or otherwise. And in the same way the phrase "dilatation
of the heart" is now in everybody's mouth, irrespective of
considerations of its origin. Not only has the profession suddenly
woke up to the recognition of a form of enlargement of the heart
which was fully described fifty years ago by physicians in our own
country, but the public have made "dilated heart" a fashionable
disease which calls for the advice of a specialist and an annual
visit to a Continental spa. We ought to have advanced beyond this
stage of cardiac pathology long before this time. Besides, of how
much greater interest is it in our every-day work to study the
causes or circumstances that lead up to disease than the simple
state of disease itself! And there is in a study of this kind
an opportunity afforded to the family practitioner of advancing
Medicine--scientific, preventive and therapeutical--as surely as if
he were a pathologist in the _post-mortem_ room or laboratory.

Before, however, examining the influences and circumstances which
disorder and damage the circulation in middle and advanced life, let
us see what the normal or natural state of the heart and arteries
is after 40. It has been ascertained that the different parts of
the circulatory apparatus pass through certain definite phases
of change in the different stages of that decline of existence
and energy which leads to senility and ends in death. We have to
thank Professor Beneke, of Marburg, for the results of a laborious
investigation of this subject which are generally accepted and which
I will attempt to summarise.[1]

  [1] F. W. Beneke, 'Die Altersdisposition.'

We should all expect the cardio-vascular system to undergo important
changes with increasing age; but few of us would be prepared to
find that these changes are neither uniformly progressive nor
indeed continuously progressive in the same direction. To make
more easily intelligible the nature and as far as possible the
origin of these anatomical alterations in the heart and arteries
during the second half of life, I will first refer for a moment
to the circulation from 20 to 45. During this period of life the
blood-pressure is relatively high, reaching its maximum about 36;
the aorta and other large arteries increase in diameter from the
stress of the blood-pressure on their elastic walls, particularly
between 35 and 45, and the heart increases in size year after year
at a nearly uniform rate. We have in these facts anatomical evidence
of the great functional vigour and activity of the circulation in
manhood. At 45, which is practically the commencement of the period
with which we are concerned, remarkable changes occur. Whilst the
arteries continue to increase in circumference (somewhat more slowly
than before), the blood-pressure falls and the heart begins--almost
suddenly--to diminish in size; and these three features characterise
the circulation for the next 20 years, that is, until the age of
65. How is this fall in the size of the heart to be accounted for?
Partly by the widening of the arterial trunks and the consequent
fall of pressure. But not by these only; for although the arteries
had been widening even more rapidly between 20 and 45, the pressure
was actually at its maximum then and the heart large, and we shall
presently find other facts opposed to this view. The peripheral
resistance in the systemic arteries must fall from some other cause
or causes in middle age than the loss of elasticity of the arterial
walls, and these causes are probably reduction of mechanical stress,
due to comparative bodily relaxation, loss of vaso-motor tone in the
splanchnic area, and the chronic diseases of which the subjects have
died whose hearts and vessels are measured _post mortem_. During
this phase of life also, the blood becomes more venous in quality
and its hæmoglobin value is lowered.

At 65, other changes which occur in the heart and arteries are
not less striking than those which I have just described. The
decline of circulatory energy, and the effects of time itself
on the protoplasm of the cells of the body, have so lowered the
metabolic and functional energy of the tissues and organs and the
activity of the blood-supply, that a considerable proportion of the
capillary network becomes obsolete. The peripheral resistance is
thus increased, and the blood-pressure rises; therefore the heart
once more increases so much in size that at the end of the 10 years
(age 75) it is found as large as it was at 45, and at the same
time the hæmoglobin value of the blood again proves to be higher.
During this period, also, the arteries continue to grow wider and
thicker and longer--another proof that the size of the heart is
not determined solely by their calibre. Regarded as a whole, the
process of senescence of the cardio-vascular system presents to us a
beautiful instance of anatomical readjustment and compensation--the
counterpart, in a way, of the growth of the circulation in energy
and activity during the period of full manhood. The arterial walls,
which have been stretched in their diameter and in their length by
exhaustion of their elasticity under the stress of cardiac systole,
are strengthened afresh by the development of stays formed of
fibroid and muscular tissues in the intima and media; and the heart
responds to the altered mechanical condition ahead of it in the
arteries, and to the increased peripheral resistance caused by the
obsolescence of many capillaries, by growing afresh.

This account relates to the size of the arteries after 40; now let
us inquire what is the condition of their structural elements. The
changes described do not necessarily involve disease of the tissue
elements, unless we were to call every senile change morbid. My
friends Dr. Bosanquet and Dr. Mullings have given me an account of
the state of the heart and aorta in the bodies of 25 men, aged 40
and upwards, examined in the _post-mortem_ room of Charing Cross
Hospital, who had died from accident or suicide. The average age
was 53½ years, and the aorta presented some degree of atheroma
in half the cases. When we consider how very slight a change in the
arch of the aorta is habitually described as "atheroma," and that in
a few of the cases the valves were diseased and the heart enlarged,
we are justified in concluding that in the majority of persons of
53 the arteries are still sound. This result is in accord with that
obtained by the late Professor Humphry, who devoted his attention so
long and so successfully to the investigation of old age. He states
that in the great majority of cases the arterial system appears to
present a healthy condition in those who attain to great age.[2]
Even among the majority of centenarians the evidences of arterial
degeneration were not manifest.[3] And we know that we occasionally
meet with people of 80 and upwards whose pulses are unexceptionable,
beyond presenting a trace of thickening and enlargement.

  [2] Humphry, 'Old Age,' 1889, p. 23.

  [3] _Op. cit._, p. 48.

For my present purpose, therefore, we may conclude that as age
advances, the arteries naturally become wider, longer and thicker,
and altogether larger than in early life; and that we must not
speak of "vascular degeneration" in an evil sense as often as we
find these conditions present. As for the heart, we know that it
may remain structurally sound, and is more often regular than
irregular, to the most advanced years of life. Conversely, these
facts suggest that actual diseases of the arteries and heart, that
is, other than the changes which are found in all persons after 45,
are not properly senile in their nature. As Professor Humphry said,
they are no part of, but are rather to be regarded as deviations
from, or morbid departures from, the natural phenomena.[4] They
must be the effects of pathological processes due to a variety of
pathogenetic influences which assail the circulation. Now we are in
a position to study these.

  [4] Humphry, 'Old Age,' 1889, p. 15.

After the age of 40, many of the influences that threaten the heart
and arteries with disorder and disease are peculiar to this period
of life--that is, different and distinct from the causes of cardiac
and vascular affections in childhood, adolescence and manhood;
others of them have been encountered already, with or without
permanent damage as the result. I will now examine them in detail,
and at the same time refer to certain provisions with which the
heart and arteries are endowed for resisting them and recovering
naturally from their effects, as well as to the circumstances
which render these provisions abortive or insufficient, and thus
predispose to disease or indirectly determine its occurrence.

       *       *       *       *       *

1. _Physical stress_ is still a definite cause of cardiac and
vascular damage during the second half of life, in the forms both
of sudden violent exertion and of ordinary laborious occupations.
I have met with instances of acute and serious strain at all ages
over 40, up to and even after 70. I am aware that I must speak on
this part of my subject--the evil effects of muscular exercise--with
great caution in the presence of you, Sir, our President, who
have long been recognised as one of the principal patrons in our
profession of athletic sports, and so highly distinguished yourself
in them at Oxford and in the inter-University contests. I assume
that you are unwilling to admit that muscular exercise is dangerous
to health. But I feel sure that you will agree with me that when the
man of 65 rushes from his breakfast-table to catch his train, or
the lady of 70 hurries up a hill in Wales to be in time for morning
service, or the middle-aged father on holiday, who has just started
a bicycle in order to reduce his weight, takes the pace from his son
of 17, the effect on the heart and arteries is likely to be serious.
I have notes of a good many cases of cardiac strain in middle-aged
and old persons from cycling; a very few from violent efforts
to drive at golf; a few from efforts at lifting or resisting
heavy weights; and one notable case in which a member of our own
profession, a man of 45, belonging to the Royal Army Medical Corps,
broke down with acute cardiac dilatation during General French's
memorable ride to relieve Kimberley. In some of my cases there was
no reason to believe that the heart was other than sound before the
strain; but in a majority of them (and I have analysed 40, of which
I have more or less full notes) one or more of the safeguards of
the circulation against strain were already defective or wanting.
What are these? In the heart, chiefly a high degree of extensibility
or elasticity of its tissues, permitting over-distension of the
chambers, with safety-valve action of the tricuspid in extreme
cases, and a sound and vigorous musculature to effect the increased
action, and if necessary the hypertrophy, which mechanical stress
demands--in a word, healthy, well-nourished cardiac walls. It is
an interesting fact that two-thirds of my cases of cardiac strain
in the second half of life presented also a history of gout, fully
developed or irregular--in other words, a history of perverted
metabolism. Equally striking is another fact in this connection:
that in many cases the occurrence of strain in middle or advanced
age was but the latest of a series of similar events as the result
of muscular effort for a period of 10, 20, 30, 40, or even 50
years--in other words, the heart had been strained originally in
youth or early manhood, and had given serious trouble as often as
it was taxed again. Rowing or running at college was in a good many
instances given as the cause of the first strain. I need not do more
than mention previous valvular disease, usually of rheumatic origin,
as a condition powerfully predisposing to cardiac injury by physical
exertion. Excepting in this indirect way, rheumatism has no effect
in lowering the resistance of heart or vessels to mechanical stress.

The principal safeguard which the arteries possess against strain
is, of course, the extensibility and elasticity of their tissues.
Unfortunately the metabolic disorders, including gout, which we have
just found weakening the cardiac walls, are amongst the commonest
causes of arterial degeneration also; and the two influences--gout
and strain--acting together no doubt are accountable for a
considerable number of cases of atheroma and chronic arteritis. It
naturally might occur to us that gout and exertion could not well
be associated, but this very consideration serves to explain their
mutual influence in straining the heart. It is unwise, ill-timed,
ill-planned muscular exercise that injures the circulation, most
often on the part of the middle-aged man, who, awaking to the
consciousness of growing fat and gouty, rushes inconsiderately to
violent exercise for relief.

2. It is generally recognised that nervous excitement and other
_nervous influences_ tax the circulation; and endless phrases
and expressions, articulate and inarticulate, testify to the
universal belief in the close connection between the heart and the
emotions. Quite recently Dr. Leonard Hill and Dr. George Oliver
have demonstrated instrumentally the rise of blood-pressure that
accompanies cerebral activity.[5] No doubt many cases of disorder
and disease of the walls of the heart and arteries originate in
distress, worry, anxiety and protracted suspense; and the connection
is most often seen in middle and advanced life, because these
depressing emotions fall most heavily upon mankind at this period.
Of the instances which I have met with I will mention but one or
two by way of illustration. A member of the Reform Committee at
Johannesburg at the time of the Jameson Raid, who had been confined
in Pretoria Jail, came home sometime afterwards with the ordinary
symptoms and signs of fatty degeneration of the heart, and died
suddenly on the street. A detective officer who had tracked suspects
and criminals all over the world, facing great personal danger,
and on one occasion had to convey a parcel of dynamite found
near a Government office to a place of safety many miles away,
came under my care later on with arterial sclerosis and cerebral
thrombosis, for which no other cause but a life of adventure could
be discovered. These were cases of actual disease of the heart and
arterial system respectively; and I need not add that disturbances
or disorders of the circulation, of every degree and variety, the
result of nervous excitement or depression, come constantly under
our observation, especially in women. I would particularly mention,
however, a group of cardio-vascular troubles that lie between these
two extremes. I have frequently observed that persons of anxious
and energetic temperament, burthened with responsible work of a
heavy, constant and prolonged character, when they break down,
as they often do, present the clinical features of high tension:
the pulse is full, the heart is large, the second aortic sound is
loud and ringing; there is polyuria, and a trace of albumen may be
found. This disturbance of the circulation, strongly suggestive of
contracted kidney, is as common in women as in men--for instance,
in matrons of schools or hospitals. Nevertheless, however clear
the direct connection between nervous strain and cardio-vascular
disease may be in many instances, it is in other instances unreal,
or more correctly indirect only. This is a matter of great practical
importance. First, the nervous temperament often drives the subjects
of it to physical overwork in the form of incessant and prolonged
devotion to work, with insufficient hours of rest and sleep, and to
unwise attempts to remove nervous exhaustion by violent muscular
exercise, as we have just seen. In the second place, alcohol
undoubtedly plays an important part in many instances regarded
as overwork and worry and nervous exhaustion, both in men and in
women--alcohol taken to enable more work to be accomplished, to
steady the nerves, to promote sleep, to drive away care, or to
relieve the faintness which it has itself induced. And thirdly,
many of the complaints of nervous depression, lowness and worry are
really due to gout, to influenza, and the like, which are at the
same time the true causes of the cardiac symptoms.

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

3. What I have just said in connection with nervous causes of
cardio-vascular affections brings us naturally to that important
group of agents which may be summarily called _extrinsic cardiac
poisons_--alcohol, tobacco, tea, coffee and lead. I will not
dwell on this subject at present, for there is no need to prove
the reality of the connection, and I shall have occasion to refer
to some of these poisons at greater length under the head of
diagnosis. Alcoholic heart occurs both in men and women; tobacco
heart is extraordinarily common in our own profession, and common
in clergymen and in retired members of the public services; tea-,
coffee-, and cocoa- poisoning I have met with principally in
students.

4. There can be no question but that by far the most prolific causes
of cardio-vascular disorder and disease after 40 are _disturbances
of metabolism_, including gout--at any rate amongst the middle
and upper classes in this country. This period of life brings
with it in many instances comparative relaxation from work, and a
disposition to substitute quiet or even passive for active exercise;
and whilst the demands of growth and development on the alimentary
system have greatly declined, the pleasures of the table and ease
generally are too often indulged in as a privilege of advancing
years and the legitimate reward of previous years of work. The
results are functional disorders of the liver, gout in regular and
irregular forms, gravel, and the many associated disorders of the
muscular, nervous and other systems. At the same time the arterial
tension rises, for the body possesses a physiological provision for
eliminating the nitrogenous products of metabolism, whether normal
or abnormal, namely, the kidneys, the vaso-motor mechanism and the
heart. Stimulation of the vaso-motor centre by nitrogenous waste
raises the arterial pressure; the heart is excited to more vigorous
contraction (if necessary it hypertrophies); and the consequent
polyuria washes the intrinsic poisons out of the system. Thus it
happens that in metabolic disorders, from excessive or unwholesome
eating and drinking, the heart, vessels and kidneys are kept under
incessant strain; and, like other organs working under strain in the
gouty subject, they are the readiest to suffer--first from disorders
of many kinds, and ultimately, unless reform be enforced, from
cardio-vascular degeneration and chronic Bright's disease.

Of the many cases of this kind that I have seen at all ages between
40 and 80 (and others before 40), the proportion of irregular gout
to acute articular gout was about 3 to 2. Under irregular gout
I include goutiness in its many forms--sick headache, eczema,
sciatica, lumbago, acid dyspepsia, irritable bladder, asthma,
insomnia, vertigo, depression, and the familiar complexion and
appearance generally of "the gouty individual," all variously
combined.

In other cases the metabolic disturbances come before us not as
gout or even goutiness in the ordinary acceptation of the term,
but in the forms of obesity, of diabetes, of gravel, of irregular
albuminuria, and of the effects of large eating and free living in
general.

5. _Syphilis_--that fruitful cause of vascular disease, and both
directly and indirectly of cardiac disease--has by no means ceased
to attack the organs of circulation after 40. Whatever the date of
the primary infection, syphilis is a standing danger to the heart
and arteries in the middle-aged man and even in declining years.
Thus, in 11 cases belonging to this group, the average age at which
they came under my observation (most of them but not all complaining
of cardiac distress) was 55. All of these were men. I ought to add
that in a considerable proportion of the cases either physical
strain, alcohol, tobacco or Bright's disease was associated with
syphilis in the etiology, and sometimes more than one of these.

6. For the man and woman of forty years of age and upwards, most
of _the acute specific fevers_ are affairs of the past. But the
liability to several of them remains, and, very unfortunately, the
liability to those acute specific processes which may attack the
cardio-vascular system--influenza in particular, and less often
typhoid fever, rheumatism, diphtheria and pneumonia, as well as
septicæmia of different forms or kinds, which works havoc throughout
the entire circulation. I should have had more to say under this
head but for the fact that our distinguished Fellow and former
President, Dr. Sansom, has thoroughly investigated it, and on more
than one occasion laid the results before you.

7. I will not occupy your time this evening in tracing the
origin of certain cases of cardio-vascular disease in middle and
advanced life to _chronic affections_ of different kinds. Besides
the obvious effects upon the heart, blood and blood-vessels, of
anæmia, exhaustion, &c., we meet with such grave lesions as fatty
degeneration from pernicious anæmia and other blood disorders;
profound circulatory derangements and occasionally valvular lesions
in Graves's disease, and others.

8. I now pass on to _complex causes_. In addition to the definite
and distinct influences which I have mentioned as threatening the
heart in this stage of life, there are two which are intimately
associated with other causes of cardio-vascular disease, but still
deserve to stand out independently. The first of these is emphysema,
and along with it other chronic affections of the lungs and pleura,
which strain the right ventricle; the second is chronic Bright's
disease, which similarly strains the left ventricle. I shall have
frequent occasion to return to these two morbid states in different
parts of my subject. I mention them here to give them the position
which they deserve as influences that threaten the function and
still more the structure of the heart and arteries. They are often
associated with each other, and each or both of them with one
or more of the unfavourable influences I have just enumerated,
particularly alcohol, disordered metabolism and gout. And this
brings me to the many instances in which the different influences
that threaten the circulatory organs in middle and advanced life act
together in different combinations. Alcoholism is equally common
amongst the poor, whose circulation is subjected to mechanical
stress, whilst it is impoverished by want; the well-to-do, who lead
luxurious, sedentary enervating lives; and, as I have already
observed, the keen active business or professional man who overworks
his brain on stimulants. In this country at least, gout appears to
be all-pervading, and as an unfavourable influence on heart and
vessels it often cannot be dissociated from alcohol, sedentary
habits, worry, plumbism, Bright's disease and emphysema.

Thus, in our study of combinations of morbific influences we come
to appreciate the evil effect of certain _occupations_ upon the
circulation in middle life. The business man is exposed to the
unhealthy actions on his heart of confinement to a close office
or shop, worry, irregular hasty feeding, alcoholic indulgence in
connection with his trade or profession, and unwise attempts at
violent muscular exercise at the week-end or in the holiday season;
or he may be guilty of entire disregard of the rules of bodily and
mental hygiene, and bring on in this way premature degeneration of
his cardio-vascular system. Still more numerous are the causes at
work in the production of "soldier's heart." We have but to picture
to ourselves, if we can, the physical strain, the mental excitement,
the bodily hardships--including exposure to both extremes of
temperature--and the coarse fare which have been the lot of many
thousands of our brave troops in the Boer war, to understand how the
fighting soldier "ages" quickly, and, in particular, ages in his
heart and arteries. Add to these unfavourable influences syphilis,
alcohol and tobacco (which, unfortunately, must be added in many
instances), and the chance of escape from disease of the circulation
in the soldier is practically _nil_. But "soldier's heart" is also
met with elsewhere than in the army. The clergyman from the slums
of London or other great city, who has lived and toiled and--it may
be said truly--has fought with various success through alternate
periods of excitement and depression, and has thus suffered much
both in mind and body, comes to us with high-tension pulse, a
tortuous radial artery, a large heart and a systolic murmur over
the aorta, and complains of an attack of angina. His wife, who has
laboured in the parish for years (she is 76, and still active in her
work of charity), has also a thickened radial artery, a large heart,
and a systolic basic murmur, with no discoverable cause of these
evidences of a diseased circulation but the life that she has led
amongst the poor around her. Perhaps such cases of cardio-vascular
disease might be most correctly said to be due to the wear and tear
of life. They are met with also in the traveller or explorer, who
has spent most of his life in search of adventure; and they are
found in a man who has never left home, but whose years have been
filled with the toil and anxiety of his position as an owner of
land, or with prolonged litigation.

       *       *       *       *       *

Such are the principal natural influences which individually or
in different combinations threaten or assail the sound heart and
blood vessels after the age of 40. I have given but a broad, hasty
sketch of them entirely from my own recent observations, and I
know that I have omitted some which in your opinion might deserve
mention, but which possess no special interest in relation to this
period of life--for example, the agents of acute infections of
the endocardium, and also new growths, pregnancy and parturition.
Let me now sum up the results, and say that whatever changes the
cardio-vascular system may present in middle and advanced life,
beyond those which we have found to be natural to it at those
particular periods, are pathological--the result of physical stress,
nervous influences, extrinsic poisons, disturbances of metabolism,
syphilis, acute disease, or chronic disease; or are associated
with chronic nephritis, emphysema or different combinations of the
preceding causes, with various occupations or positions in life, or
with other influences of less importance. It is necessary, however,
to qualify this statement in two respects. In the first place, the
heart and vessels may have been so damaged already, that is, in
early life, that they fall victims to influences which, whether
in kind or in degree, would have been insufficient to produce
idiopathic disease of these organs. This brings me to the subject of
old-standing valvular disease (mostly rheumatic in origin), chronic
strain, and adherent pericardium in middle-aged and old subjects.
A considerable proportion of our cases are of this type, and they
have to be mentioned here for the sake of giving completeness to
the plan of arrangement, but they are outside the range of our
immediate subject. In the second place, hearts and arteries at 40
that appear to the naked eye free from damage may be molecularly
weak, and unable to offer effective resistance even to influences
of an every-day character. I have now arrived at the last, and
certainly one of the most interesting, of the causes of disease of
the heart and arteries in middle and advanced life. There are some
persons whose hearts and arteries cannot carry them through the wear
and tear of what may be called ordinary life for more than 40 or 50
years. The vital energy of the tissues of these organs is exhausted
prematurely; they are already old at 45; degeneration of the
muscle and other cells sets in early, reminding us of the essential
myopathic paralysis of children. This type of case is described as
"family heart," for it also runs in families--three, four, five,
or more members of which, as in a number of instances that I have
observed, may have all died suddenly of cardiac disease--some of
them at an early age. Similarly, it is not by any means unusual to
find quite young subjects, say of 30, with vessels already much
enlarged; and I may add, equally young subjects with their lungs
already emphysematous although there is no history of respiratory
strain, reminding us of the very common association of emphysema
with arterial sclerosis in old age. These cases of family heart and
premature arterial sclerosis are the links that connect disease of
the heart and arteries in middle and advanced life of definitely
pathological origin with the genuinely senile changes in the
tissue-elements which render existence untenable at last, and which
may be said to be the result of the exhaustion of their nutritional
activity by "the thousand natural shocks that flesh is heir to."




LECTURE II.


MR. PRESIDENT AND GENTLEMEN,--In my last lecture I presented to
you a brief account of the condition of the organs of circulation
between the ages of 40 and 75, and I then proceeded to direct your
attention to the principal influences which may disorder and damage
them during that period of life. I will now attempt to describe
the clinical characters and course of the affections of the heart
and arteries, as I have observed them, in connection with these
different influences respectively--whether gout, mechanical stress,
syphilis, or other. Thereafter, if time permits, I may be able to
examine the different symptoms and signs individually in order to
discover the value of each as a guide in diagnosis.

Now, as I have already pointed out, the causes of cardio-vascular
disease in the second half of life are very often, indeed usually,
complex. It follows, therefore, that if we desire, as we do most
particularly, to discover the effects of each pathogenetic influence
as distinguished from the others, we must begin our study with the
simplest, or purest, or most definite of all, and proceed from it
towards those which are more difficult, as well as to combinations
of causes. It is easy to adopt this method in our present inquiry.


TOBACCO HEART.

We have in tobacco a single distinct influence at work; one that is
universally acknowledged to affect the heart and vessels, and the
physiological action of which is understood; one, further, that can
be removed (perhaps not without some difficulty, for I have had a
patient plead for his pipe with tears in his eyes), and certainly
that can always be resumed with remarkable readiness--in a word,
a most favourable subject of observation by experiment. It is
well, too, to begin the study of tobacco heart in young men, whose
circulation is still structurally sound, and thereafter to follow
up the subject in middle-aged and old persons. Adopting this line
of inquiry, I have found that the uncomplicated effects of tobacco
on young healthy hearts, as they present themselves clinically,
are: palpitation in every instance; a sense of irregular action,[6]
post-sternal oppression and pain in half the cases; and in one out
of every eight sufferers either angina or uncomfortable sensations
in the left arm. Faintness or actual faints occurred in one-third,
and giddiness and a feeling of impending death in a smaller
proportion. Turning to the physical signs, the heart proves to be of
ordinary size in 50 per cent. of the patients; in a few it is very
slightly enlarged; the præcordial impulse is often very weak, but
occasionally increased in force and frequency, and almost as often
irregular as not; the pulse tension, with insignificant exceptions,
I have always found low. Very interesting, in the light of what I
shall tell you later on, is the fact that of 20 of these patients
complaining of the heart not one presented a cardiac murmur beyond a
weak mitral systolic bruit, varying with posture or cubitus. This is
in accordance with the teachings of pharmacology --that tobacco acts
on the terminal branches of the vagus.

  [6] A medical friend who has suffered from tobacco heart assures
  me that at one period he could distinguish the contractions of the
  auricles and ventricles.

Now we are in a position to study the tobacco heart in a man of 40;
and again let us begin with a man who is sound, active, and healthy
otherwise. He complains of his heart, and recognises willingly
(for he belongs to our own profession), in the discomfort and
anxiety from which he suffers, the penalty of having smoked for
years the strongest and blackest tobacco that he could buy. Yet his
heart is not enlarged, and the cardiac sounds might be described
as ordinary were they not peculiarly irregular, the frequency
changing every moment and a falter occurring at short intervals.
There is not a trace of murmur to be found in connection with
the valves and orifices. At ages over 40 a clinical study of the
tobacco heart is highly instructive from a practical point of view.
Whilst palpitation is still the common complaint, pain, including
angina, is put forward more prominently, and so are faintness,
actual faints, a feeling of impending death, and a sense of cardiac
irregularity, each intermission being accompanied with a sudden
stab through the præcordia. Some of you will remember Mr. Barrie's
quaint account in 'My Lady Nicotine' of what he calls the horrors
of his smoking days, when the pain at his heart made him hold his
breath--"a sting" as he describes it, and he believed he was dying.
In these subjects the heart is more frequently found to be large and
feeble; the same weak systolic murmur is occasionally to be heard;
the radial pulse is often irregular, and the vessel wall naturally
thick. This, you will notice, is a combination of symptoms and signs
sufficient to alarm the casual observer. But when we examine it more
deliberately, in the light of our study of the tobacco heart in
young subjects, on the one hand, and of our knowledge of the normal
or natural condition of the heart and arteries at 60, on the other
hand, we are able to reassure ourselves and our patients. We are
justified in concluding not only that every cardio-vascular lesion
which may be found in tobacco smokers is not to be put to the credit
of tobacco, but, _vice versâ_ (and this is of more interest to us in
our present inquiry), that every præcordial pain, angina, faintness,
or irregular pulse in a man of 60 with a full-sized heart is not to
be hastily regarded as evidences of grave disease without further
inquiry as to his habits. The cardiac enlargement and large pulse
may be nothing more than the result of a life of bodily and mental
activity: the præcordial distress may be the result only of tobacco.
How very necessary this caution is will be impressed upon your
consideration by the two following cases. The first is that of a man
of 60, actively engaged in professional pursuits, who first suffered
from præcordial pain of an alarming character four and a half years
ago, and has had attacks since, particularly during exertion and
after meals. One day last autumn, at the end of many hours' hard
work, cheered by at least 18 cigarettes, he was rushing off to dine
with a friend when he was suddenly seized with præcordial pain which
he described as fearful, radiating down the left arm. He broke into
a cold sweat, thought that his last hour had come, and for a short
time had impairment of consciousness. Shortly after this event he
took the advice of his doctors and gave up tobacco (shall I say for
a time?), and from that day to this, now six months, he has had no
further trouble with his heart.

The second case is equally striking. A man of 55, of fairly active
disposition and somewhat full habit of body, was suddenly seized
with angina pectoris in October, 1899. The pain was of a dull
bursting character over the region of the heart, and it passed into
the left shoulder, down to the elbow, and settled particularly in
the wrist. At the same time there was pain in the upper maxillary
region. The heart slowed down from 75 to 50, and the sufferer felt
that he was dying. From that time anginal attacks occurred in
rapid succession, five, six, nine or even eleven in a single day;
occasionally they came on in the night. This experience continued
for nearly two months on end; indeed, it was six months before the
angina finally ceased. It was instantly relieved with amyl nitrite;
nitro-glycerin was unsuccessful. In the course of giving advice to
this patient I fortunately discovered that he had just laid in a
stock of 2,000 cigars. The line of treatment was obvious; and the
result has been, as I have said, complete recovery.

I have dwelt on the subject of tobacco heart perhaps longer than
was necessary, addressing, as I am, a meeting of practitioners of
experience and not a class of clinical students. I have done so to
bring home to us an important consideration which we are all apt
to overlook in diagnosis and still more in treatment, namely, that
whether in an ordinary senile heart, or in a heart that is the seat
of chronic valvular disease, or in arterial degeneration, something
more than the pathological changes have in many instances to be
regarded--usually some entirely adventitious disturbance which alone
calls for treatment, such as indigestion, flatulence, worry, a
bronchial catarrh, or it may be free indulgence in tobacco, tea or
coffee.


THE HEART IN ALCOHOLISM.

Let us now pass on to consider, from the clinical point of view, the
effect on the organs of circulation of another morbific influence
of a definite kind, namely, alcohol, or perhaps more correctly
alcoholism, leaving on one side the questions of form and strength
of the drink taken and its purity.

The direct effects of alcohol on the heart and the blood-vessels are
by no means so easily determined as those of tobacco. In the first
place, they are complicated with the many indirect effects which it
produces on these organs by deranging the functions of alimentation
and assimilation, the nervous system and the kidneys, and with the
secondary effects on the vessels and heart of chronic nephritis
due to the same cause. In the second place, as we saw in my first
lecture, alcoholism is very commonly associated with nervous strain,
with gout and goutiness, with tobacco, with syphilis, and not
uncommonly with two, or more, or all of these together. Eliminating
as far as possible these sources of error by careful selection of
cases, I find that the alcoholic heart in middle and advanced life
presents clinical characters, as a whole, very different from those
of tobacco heart, which we have just studied. The most striking and
important of these are the evidences of actual pathological change
in the size of the heart and the condition of the myocardium. We
found no evidence that tobacco causes serious cardiac enlargement,
and neither may alcohol in quite young subjects, who present mainly
excited action both in force and in frequency. But of 28 cases of
alcoholic heart which I examined clinically in connection with the
present inquiry in older subjects, only two hearts were of ordinary
size (and as a matter of fact both of these patients were under
40 years of age). This result is in accord with my pathological
observations. For instance, I have carefully followed the condition
of the heart in an intemperate man of 43, and _post mortem_ found
the heart to weigh 17 ounces, to be universally dilated in all
its chambers, and to present enlargement of the mitral opening
without valvular lesion, corresponding with a weak apex systolic
murmur heard during life. These results are also in accord with
those in Dr. Maguire's cases of acute dilatation of the heart from
alcoholism, which he recorded as long ago as 1888[7] (when, I may
add, doubts were expressed of the correctness of his conclusions
by several of our best authorities on cardiac disease), and one of
which occurred in a man of 23. Dr. Mott has found fatty degeneration
of the myocardium in patients dying suddenly during alcoholism.[8]
With hardly an exception the præcordial impulse is weak--indeed,
it is often imperceptible; the sounds are small and feeble, and
may be almost inaudible; in 20 per cent. of my cases a weak apex
systolic murmur could be heard, varying with posture and from day
to day, significant, no doubt, of leakage through a dilated mitral
opening. The alcoholic heart is irregular and accelerated in about
half the cases. The pulse tension is usually low; in one-third of
the instances the radial artery was sclerosed; in one-fifth of them
there was slight albuminuria; the legs may be 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.

Syphilis appears to account for a very considerable proportion of
the more serious cases of heart disease which we meet with in older
subjects--excluding of course chronic valvular disease originating
remotely in endocarditis. But I ought to repeat here what I have
already mentioned, that syphilis as a cause of cardio-vascular
lesions is very often associated with other morbific influences,
particularly strain and alcohol. Of its position as the principal
cause of grave disease of the valves as distinguished from the walls
of the heart, originating in middle life, there can be no question.
No fewer than nine out of 28 cases, of which I have private notes,
were the subjects of double aortic disease; practically all the
others had a loud ringing second sound over the aorta, significant
of degeneration; pain of anginal type in half the cases was the
prominent complaint; and two-thirds of the subjects had sclerosis
of the radial artery. When we consider that syphilis does also
affect the myocardium primarily; that fibroid disease, chronic
aneurysm and fatty degeneration of the heart are all traceable to
specific disease of the coronaries in many instances; and, finally,
that many of the subjects of syphilitic cardio-vascular disease
have perished before 40, the magnitude of this cause can be fully
realised. I believe that the profession in general have not yet
woke up, if I may say so, to the gravity of this subject. How
seldom we inquire for a history of specific disease in patients
coming to us with cardiac disease in middle life! To no one, as
far as my reading goes, are we so much indebted for the truth on
this subject as to my friend and colleague Dr. Mott. Thirteen
years ago he published a paper on 21 cases of sudden death from
cardio-vascular disease, and in nine of these there was a history of
either actual or probable syphilis. What was of greater interest,
however, at that early date, he drew attention to the association
of syphilitic cardio-vascular lesions with Bright's disease in the
broad acceptation of the term. Dr. Mott's work in the interval on
syphilitic lesions of the arterial system of the brain has been so
brilliant, and is so generally known, that it requires nothing more
than this appreciative mention by me, and it saves me the trouble of
an excursion into the subjects of cerebral hæmorrhage and thrombosis
in connection with these lectures.


NERVOUS STRAIN.

I confess that it is difficult to say much that is of real
diagnostic value on the clinical aspect of cardio-vascular disorders
and disease from nervous strain. As I remarked in discussing this
subject from the etiological point of view, several factors come
into play besides nervous excitement followed by exhaustion and
their effects on the heart, great vessels and cerebral arteries;
and the cases, therefore, are found to present a puzzling variety
of features. Certain clinical characters are, however, common to
the majority. Arterial tension is high; the radial artery is thick,
sometimes markedly so; the heart enlarges; and in about one-half of
the cases a systolic murmur is to be heard either in the aortic or
in the mitral area, significant of chronic endocardial lesions--all
readily intelligible results of cerebral strain in the light of
our knowledge of the innervation of the cardio-vascular system. I
have already pointed out that in some of these patients polyuria
and temporary albuminuria occur along with the high tension and
the increased action of the heart; but the heart may fail later
on. The direct cardiac symptoms of which they complain are of the
ordinary character, palpitation with accelerated cardiac frequency
and pain (not angina) being the most common at first, feelings of
indescribable discomfort and suffocation in the more advanced stage.
A great deal that I might have had to say on the very interesting
subjects of pseudo-angina, and the climacteric and pre-climacteric
disturbances of the circulation in women, I am reluctantly compelled
to omit from want of time.

       *       *       *       *       *

After having reviewed, as I have attempted to do, the principal
clinical characters of the disorders and diseases of middle and
advanced life under their several causes, it may appear for a
moment strange that the most important of all the clinical types of
cardio-vascular degeneration has been mentioned only incidentally.
This is chronic Bright's disease, which, from its complex
pathological relations, its widespread effects on the heart and
circulation and the organs that they supply, and the far greater
gravity of these than those of any of the other causes which we have
studied (unless it be syphilis), is a subject of endless interest to
us all. Fortunately for me my immediate predecessor in this chair on
the medical side, our distinguished Fellow, Dr. Samuel West, took
for his subject the "Clinical Aspects of Granular Kidney," and thus
relieved me of a task which he was so much better able to discharge
than I. Emphysema must also be passed over with the single remark
that it is a very common accompaniment both of vascular and cardiac
degenerations.

I trust you do not conclude that the description which I have just
given you of the clinical characters of these various disorders and
diseases of the heart is in any sense complete. It only relates to
the most prominent symptoms and signs as they present themselves to
us in what might be called the every-day life of the patient, at a
period in the history of his case precedent to failure. In all of
them there may occur occasional attacks of acute embarrassment of
the heart and lungs from one or more of a variety of causes, such
as indigestion, excitement or over-exertion. Sooner or later, also,
there occurs either cardiac dropsy--insidiously developed after
increasing local distress, growing dyspnœa and "bad nights"; or
Bright's disease; or cerebral thrombosis or hæmorrhage, or acute
myocardial failure with angina: or the patient dies from failure of
the heart in the course of some acute disease such as bronchitis or
pneumonia. Neither have I considered it necessary in this lecture to
dwell on some of the rarer phenomena occasionally met with, such as
tachycardia and bradycardia. I may have occasion to refer to them
next time in connection with prognosis.




LECTURE III.


MR. VICE-PRESIDENT AND GENTLEMEN,--In this, the concluding lecture
of the series, I will attempt to deal with the applications of
the facts and considerations which I submitted to you on the two
previous occasions when I had the honour to address you. I trust
that what I then laid before you proved to be of some interest.
Let us see now whether it is practically useful. However much the
etiology and pathology of the diseases and disorders of the heart
and arteries in middle and advanced life may deserve study as
matters of natural history, we should be disappointed if they could
not be turned to account in prognosis and treatment. These are the
subjects I propose to discuss this evening.

Now, prognosis and treatment, to be rational and useful, have to be
based on as full and as correct a diagnosis as knowledge permits.
The present disposition is to fall short of this; to rest content
with an incomplete diagnosis. We say that the patient's "heart
is dilated," that he has "arterial degeneration," that there is
"fatty degeneration." But you will remember that we have found that
cardiac dilatation may be present in every kind of cardio-vascular
degeneration; that the arteries are naturally enlarged and thickened
after middle life, and that we refused to call these changes morbid.
Clearly, therefore, a purely anatomical diagnosis of this sort
is insufficient. If you are asked what the prognosis is of fatty
degeneration of the heart, you answer that you must first be told
whether syphilitic or gouty disease of the coronary arteries, or
strain, or alcoholism, or phosphorus-poisoning or anæmia is the
cause of it. When you are planning the treatment of dilatation of
the heart you first determine whether the dilatation is a result
of the stretching of a sound heart by overfilling during muscular
effort, or of the insufficient emptying of failing chambers with
degenerated and feeble walls. Obviously what we ought to determine
in these instances and in every instance is the origin of the
disease. The ultimate diagnosis to be reached for practical purposes
is the etiological diagnosis.

Is this possible? Does our knowledge of the nature, characters and
course of these cardio-vascular affections enable us to say, after
investigating a case, what the kind of the pathological change is
that constitutes the disease, or in what respect the physiological
mechanisms are disordered? Can the cause of these degenerations of
the heart and arteries be determined in each instance? How is the
practitioner to proceed to do so? What method might be followed with
advantage in making a complete diagnosis of heart disease in older
subjects?

A man of 60 consults us about his heart. He says that it has caused
him a good deal of concern lately. More specifically he describes
a sense of oppression behind the sternum as often as he exerts
himself, and palpitation with consciousness of irregular cardiac
action when he goes to bed. We inquire for other familiar cardiac
symptoms, such as pain, angina, fluttering, faintness, giddiness,
and a sense of impending death. We find that one or more are present
occasionally, and that they have increased in number and degree
during the last few months or years. Perhaps cough, nocturnal
orthopnœa and dropsy may be beginning to give trouble. The next
part of the inquiry relates to the patient's previous history
from childhood upwards. Which of the acute diseases has he had?
Acute rheumatism, chorea, scarlet fever, typhoid, diphtheria and
influenza must be mentioned individually, and in women the nature
of any puerperal disease from which they may have suffered. Gout,
irregular gout, gravel, eczema, sick headache, asthma must be
inquired after with the same minuteness, and so must syphilis. We
next hear an account of any accident which the patient may have met
with, such as a blow, or a fall from a horse or a carriage. This
brings us naturally to question him about his occupation and modes
of relaxation and amusements--whether active or sedentary, regular
or irregular, their characters otherwise, and their direct effects,
including strain. More difficult to elicit is a correct account of
the patient's habits--in respect of food, stimulants and tobacco,
and his manner of life generally. As I said in my first lecture,
this is an inquiry which the family practitioner has an opportunity
to carry out much more successfully than the hospital physician
or consultant. The family practitioner has known for years of his
cardiac patient's work and worries; it may be of his large eating,
of his secret drinking, of the history of syphilis in earlier years.
It is always well also to inquire after a family history of gout,
rheumatism and heart disease. A list of questions like this sounds
far more formidable than it is in reality. A few minutes suffice to
arrive at the truth. We already have a pretty fair notion what we
have to deal with, whether strain, gout, syphilis, tobacco, an old
rheumatic lesion, or a combination of two or more of these.

We next proceed to physical examination, beginning with the pulse
and arteries, and passing on to the heart and associated structures.
The characters of the præcordial impulse--particularly the seat
of the apex-beat and the strength of the impulse--are closely (I
might almost say laboriously) investigated. We must never yield to
the temptation to disregard weakness or absence of the impulse.
Like many other negative signs it is apt to be overlooked. Then the
præcordial dulness is mapped out by means of light percussion.
Finally, auscultation reveals to us the presence or absence of
murmurs and the characters of the sounds--in the standing and
recumbent postures, and, if necessary, after a little exertion. The
relative loudness of the first and second sounds over the different
parts of the præcordia is particularly worthy of note.

Now let us suppose that we have found a mitral systolic murmur. We
ask ourselves whether it is structural or whether it is functional,
that is, due to relaxation and dilatation of the ventricular walls.
If structural, with which (if any) of the diseases elicited in the
man's previous history would it correspond? Most probably with
gout or glycosuria. Thus we attempt to connect the lesion with
its cause, and the cause with its effects, and have reached the
ultimate diagnosis. So with other valvular murmurs: for example,
an aortic diastolic murmur proves to be related to syphilis. If
there be no murmur audible, we naturally think of dilatation with
failure, or of enlargement from strain, from Bright's disease, from
arterial sclerosis, from emphysema, from an insufficient or impure
blood-supply in the coronary arteries, from disordered innervation,
or from some rarer cause, such as adherent pericardium; and then,
with these associations in our minds, we review once more the
patient's history, and generally succeed in our diagnosis.

Here let me recount the significance of the principal signs and
symptoms which I detailed to you in my last lecture, considered in
the reverse order on this occasion, some of which are of real value
in differentiating the causes of cardio-vascular degeneration. To
begin with negative facts: a mitral pre-systolic murmur is never
significant of a degenerative lesion. Secondly, when we meet with
an aortic diastolic murmur, whether alone or along with an aortic
systolic murmur, we may safely conclude that we have to deal with
something more than atheroma produced by regular or irregular gout
and associated metabolic disturbance, cardio-vascular disease of
nervous origin and alcoholic or tobacco heart, even if there be
evidence of the presence of one or more of these in the case.
Aortic incompetence developed in later life is the result of
syphilis, or of acute or chronic valvular strain; but, of course,
many instances of this lesion met with after the age of 40 can
be traced to juvenile endocarditis of rheumatic or other origin.
Always a serious lesion, aortic incompetence due to syphilis, or to
syphilis and strain, is particularly grave, as being so frequently
associated with coronary disease and consequent myocardial
degeneration--fatty or fibroid, acute softening, and sudden fatal
failure. A fully-developed basic systolic murmur, audible over the
aortic area and manubrium and along the course of the carotid,
is a very common sign of atheroma of the aortic arch and valves
and great vessels in association with regular or irregular gout,
diabetes, corpulence and allied disorders of nutrition. It is also
one of the physical signs of syphilitic and traumatic affections of
the aorta and aortic valves and of remote endocarditis. Further,
these lesions are so often accompanied by similar degenerations in
the coronary arteries and consequent myocardial degeneration, that
the basic systolic murmur ought at least to raise the suspicion
of this in the observer's mind. An ill-developed basic systolic
murmur is not uncommon in alcoholism, chronic Bright's disease and
nervous strain, but it is difficult to dissociate from anæmia. A
fully-developed systolic murmur audible in the mitral area, I mean
independently of ventriculo-auricular leakage in cardiac failure,
is usually traceable to early endocarditis of rheumatic or other
origin, rarely to injury, including ordinary juvenile strain of the
valves or walls, or to Graves's disease. But in some instances it
is unquestionably due to valvular atheroma and attendant sclerosis,
caused by gout or other disturbances of metabolism, including the
effects of free living; and in these instances the observer must
not overlook the possible association of coronary disease and fatty
degeneration. If a systolic mitral murmur prove to be somewhat
indefinite and affected by posture, cubitus and effort, to vary
under observation from day to day, and to disappear under treatment,
it is of no more value to us in differential diagnosis than that
it signifies relaxation and weakness, or disorderly action, of the
left ventricle, consequent on any one of the recognised causes of
failure or disturbance of the heart, including the different cardiac
poisons, overwork, anæmia, acute disease, poverty and the like, and
this whether in a heart previously sound or previously enlarged or
previously the seat of valvular disease. An accentuated ringing
second sound in the aortic area, or more extensively, is of great
value in the diagnosis of arterial tension and of aortic atheroma or
of both, but it is associated with far too many different causes to
be of much use in differential diagnosis. It should suggest a most
careful search for Bright's disease. Slight reduplication of the
first sound is common over the heart strained in youth and the heart
degenerated by alcoholism and metabolic disorders, but everyone
knows that it is not unusual in a variety of other conditions,
healthy and morbid. On the other hand, the _bruit de galop_, or
cantering rhythm of cardiac sounds--definite doubling of the first
sound followed by loud, accentuated, ringing second sound--is
practically pathognomonic of Bright's disease, and is one of the
most valuable, because one of the most ominous, of physical signs in
connection with the cardio-vascular system. A normally-sized heart
with irregularity, increased frequency, and a variable systolic
murmur in the mitral area, is characteristic of tobacco poisoning. A
heart enlarged on both sides, and acting irregularly without murmur,
is (apart from cardiac failure) suggestive of strain in early life.

Cardiac symptoms taken individually are of less diagnostic value
than signs. No symptom is pathognomonic. Palpitation is a nearly
universal phenomenon of cardiac disease and disorder. Faintness and
actual faints are not uncommon in cases of early cardiac strain,
gouty heart, and nervous disturbances. Angina we meet with, you
will remember, in regular and irregular gout, tobacco heart, strain
(especially strain after 40), and in syphilis and alcoholism,
whilst pseudo-angina is extremely common in nervous women: thus
angina is of less diagnostic value than might have been expected.
A high-tension pulse I have found most often in Bright's disease,
in juvenile strain, and in cardio-vascular affections of nervous
origin; a low tension pulse in connection with alcoholic and tobacco
poisoning, and with senile strain.

When we review these facts, I think we are entitled to conclude that
the physical signs and symptoms carefully determined by clinical
investigation may be confidently employed, along with the patient's
previous personal history, and the history of his present illness,
to differentiate from each other the causes of cardio-vascular
degeneration in individual cases. And, further, that they inform
us of the seat of at least some of the lesions, valvular, parietal
and vascular. A little trouble, patience and attentive observation
are all that are required to reach a complete or working diagnosis.
Now we may approach the great practical subjects of prognosis and
treatment with some confidence.


PROGNOSIS.

Beginning with the simplest kind of cardio-vascular disorder, let us
see what the prognosis is in tobacco heart. You will have gathered
from what I had to say on this subject in my last lecture, and
indeed you know as men of observation and experience, that it is
comparatively favourable. All the cases I have had an opportunity to
watch did well, provided the cause of their distress was avoided and
the heart and vessels were otherwise healthy. Further, improvement
begins early, and it may be rapid and recovery complete; but you
will remember that one patient, whose case I detailed to you,
continued to have alarming angina for six months after giving up
tobacco. Recurrence attends resumption of the habit, but some of
its votaries contrive to continue to smoke just short of inducing
serious discomfort. Unless a successful effort at reform be made,
cardiac trouble may continue indefinitely. But even then I cannot
say that I have seen serious damage done by tobacco alone in
sound hearts, nor arterial sclerosis, as has been stated by some
authorities.

An entirely different and most unfavourable estimate is to be formed
of the prospect of life in the alcoholic heart. Naturally, a certain
proportion of cases recover if the disease be of recent development,
the condition uncomplicated, and treatment faithfully carried
out. Unfortunately, as a rule, we have to deal with alcoholism in
which all these conditions of success are wanting. The habit is
established, other organs besides the heart are involved, other
diseases than alcoholism are present, and the patient has neither
the inclination nor the power to follow our advice. Cirrhosis,
neuritis, dementia complicate the cardiac degeneration, or, more
correctly, it complicates one or all of these. Chronic Bright's
disease is made to account for a number of deaths in the mortality
returns that strictly belong to alcoholism. Occasionally the end
comes suddenly from fatty degeneration, or in the course of some
acute disease; otherwise, as we have seen, by slow cardiac failure
and dropsy.

Prognosis in gouty heart, including the heart of the man with
goutiness, glycosuria and other irregular forms of the disease, is
a subject of considerable practical difficulty. In my last lecture
I read to you a short account of the case of a friend of my own
who had had occasional attacks of gouty angina for 40 years. And
certainly a large proportion of the old ladies of 60 or 70, whom
you all have had as patients for years on end with weak heart
and systolic murmur in the aortic area, owe their disablement
to gout, if my observations are correct. The lesion proper of
the aorta and aortic valves in these cases is atheroma, but the
damage is accompanied with repair in the form of sclerosis, which,
by increasing the loudness of the bruit, adds unreasonably to
our anxiety about the case. Equally certain it is that patients
belonging to this class improve under treatment. Still, the
condition of arrest cannot go on indefinitely. In addition to
extrinsic dangers, particularly those of Bright's disease, cerebral
thrombosis and hæmorrhage, and bronchitis, failure of the heart
is liable to supervene and prove fatal from the gravest of all
intrinsic causes, namely, coronary degeneration. As this increases,
the myocardium is steadily more and more impoverished; its
contractile vigour declines, and residual dilatation of the chambers
sets in with mechanical congestion of the viscera. Complaints of
"the heart" increase, the breathing becomes oppressed, the face
assumes more and more the characteristic "cardiac" appearance, and
dropsy creeps up the lower limbs. Even then the prognosis is not
hopeless, for undoubtedly a certain proportion of cases of dropsy in
old persons with degenerated heart and vessels are still amenable to
rational treatment. But the case has occasionally a more dramatic
termination. As I was able to illustrate after my second lecture by
a specimen from the Museum of Charing Cross Hospital, a branch of
one of the coronary arteries that has been narrowed by atheroma for
an indefinite length of time, with consequent cardiac weakness and
discomfort, may any moment become thrombosed rapidly, apparently
in consequence of some passing depression or other unfavourable
influence, just as in thrombosis of degenerated cerebral vessels.
Fatal angina is the result. This is a point of great practical
importance--that sudden death will occur in old gouty subjects not
from the lesion of which a basic or an apical systolic murmur is the
evidence and which causes us concern, but from associated coronary
atheroma, which we probably never suspect; indeed, that it may occur
in those subjects with no murmur whatsoever to attract our attention
and excite our fears.

Still more unfavourable must be the forecast in syphilitic lesions
of the heart and vessels. Of 18 of my cases in which the result was
known, only one-half improved under treatment, and 20 per cent. of
them died within a few years (some indeed within a few weeks) of the
discovery of their disease. Cardiac failure accounts for most of the
deaths, whether developed gradually with dropsy, which proves to be
intractable; or progressing rapidly with great cardiac distress,
including angina; or occurring suddenly, as it often does. Aneurysm
makes its appearance in other instances, of which the patient dies,
or he is carried off by general paralysis or Bright's disease.

What prospect have we to hold out to the man who has strained the
walls of his heart by muscular effort? I believe that one can speak
with some confidence on this subject. The middle-aged patient who
over-stretched his cardiac walls as a youth may be comforted with
the opinion that the condition is not a fatal one. The average
duration of 11 cases of this order I found to have been 30 years
when they came under my observation; the minimum duration was nine
years, the maximum 50 years. This last case deserves particular
mention. The patient was first seen by me for failure of the heart
with cardiac dropsy, consequent on fresh breakdown after exertion
during a holiday; and it is most encouraging to observe that
compensation was restored by treatment, and that now, 12 months
after that event, he is not only alive, but able to carry on light
professional work. This case also illustrates what I have told you
respecting the course of the affection, and the prospect before the
patients, in long-standing strain--that there is continual liability
to fresh embarrassment of the heart during exertion, in which they
appear to have a lasting inclination to indulge. If they happen
to follow an occupation that entails occasional effort, or effort
with excitement and worry (if they happen, let us say, to be busy
practitioners of medicine), they suffer in the same way from attacks
of tachycardia, distressing palpitation and anxiety. Indeed, as I
pointed out in my second lecture, they are readily upset by other
influences besides these, including indigestion, to which the victim
of hurry and worry is peculiarly liable; and they must be prepared
to have to lead a life of comparative temperance and self-denial.

Neither is strain of the heart for the first time after 40 by any
means so grave as might be expected. Of course, sudden muscular
effort occasionally accounts for sudden death in old men. But it
is astonishing how, under such circumstances, quite old persons do
recover from conditions of extreme distress lasting acutely for
half an hour--for instance, after running with a heavy bag to catch
a train. The majority of my patients described their condition as
improved after a time, but others relapsed; and on the whole the
correct prognosis is that they must expect to remain variously
disabled--that is, liable to præcordial distress and dyspnœa on
more than moderate exertion, or when subjected to circumstances of
other kinds that tax the heart.

Cardio-vascular disorder and disease referable to nervous strain
pure and simple is amenable to treatment by complete and prolonged
rest or relaxation in the majority of instances. Still, death may
occur from sudden cardiac failure; or should advice be neglected
or soon forgotten, as happens so frequently in these subjects,
the attendant high arterial tension and vascular degeneration too
often end in cerebral lesions, with or without Bright's disease. Of
chronic Bright's disease itself and the associated cardio-vascular
changes in their prognostic aspects I need not speak, except to say
that along with syphilis it is by far the most hopeless of all these
affections.

In attempting to forecast the life of a man who is the subject of
cardio-vascular degeneration in middle or advanced life, we must
not forget the possibility of the intercurrence of acute disease.
Here is a large subject for us as practical men--one far too large
and important for discussion here: the effect, for instance, of the
existence of enlargement of the heart and an irregular and thickened
pulse on the prognosis of influenza, or, let us say, on the chances
of a successful issue after operation. Very naturally, unsound
vessels and a murmur over the præcordia weigh heavily against the
prospect of recovery from pneumonia, for example; and yet how often
do we not find a patient of 70 with one or both of these disturbing
conditions come safely through such an illness! Here, again, I
believe it is in great measure the true nature of the old-standing
disease, not the physical signs such as irregularity of pulse or
mitral bruit, that ought to be taken into account. A heart enlarged
and a radial artery thickened by prolonged activity and nothing else
will suffice to carry a man safely through an attack of influenzal
pneumonia; but what chance is there for the chronic alcoholic under
similar circumstances, or for the subject of chronic Bright's
disease?

So much for the general prognosis in each of these kinds of
cardio-vascular disorder and disease. But it is the particular
prognosis that we have to attempt to estimate--that is, the
prognosis in the individual patient as he comes before us and
asks us that trying question, "What is my prospect of life and
health"? We diagnose, if possible, the precise nature of his cardiac
affection, and apply to the best of our ability the conclusions
which I have just submitted to you, and at the same time we estimate
as correctly as possible the man's personal condition, character and
disposition. For, whatever may be determined with respect to the
average patient by an analysis of a large number of these cases, the
individual patient's future in disease of the heart of every kind,
degenerations included, greatly depends on the care that he takes
of himself. This introduces us to another consideration. However
earnestly we may attempt to estimate the prognosis on a strictly
rational system--that is, by basing it on an accurate and complete
diagnosis--we cannot deny that when the individual patient is before
us we are influenced directly by certain of the symptoms and signs,
without asking ourselves what their respective pathological meaning
may be. True bradycardia, the story of an unmistakable attack of
angina pectoris, a loud aortic diastolic murmur, the _bruit de
galop_--these instantly give us great concern before we have had
time to translate them into the language of morbid anatomy. Very
naturally we attempt to carry this method too far, and to reach a
prognosis, as it were, by a short cut, by attaching a prognostic
value to each clinical phenomenon--palpitation, præcordial
oppression, faintness, lethal sensations, and so on. Now, quite
irrespective of the unscientific character of this proceeding, it
is of little practical service. Even when we have listened to an
account from a middle-aged man of an attack of angina pectoris,
what can we tell him of his prospect of life until we have learned
whether he be guilty of excessive smoking or drinking, whether he
be gouty, whether he have lately strained his heart or no? What
I do regard as really valuable prognostically, in the way of a
simple clinical observation, is the determination of progressive
symptoms and signs. A man of 72 complains of oppression over the
lower sternal region as often as he climbs a hill. Twelve months
later he comes and tells us that he has had an attack of severe pain
across the top of the chest during the night. Another year passes,
and he returns to say that now he cannot hasten on the street
without præcordial distress; and it is noted that the second aortic
sound, previously thick in character, is slightly blowing. By the
fourth year of observation the patient, having had influenza in
the interval, complains of an auto-audible murmur, and of actual
pain in the chest; there is now a fully-developed aortic diastolic
murmur, and his ankles swell occasionally. Prognosis was only too
easy in this case, without inquiry into either the cause or the
lesion. A few months later true angina occurred, and very shortly
the patient died, after twenty-four hours' severe suffering.


TREATMENT.

Not the least advantage of the etiological standpoint of our
survey of the disorders and diseases of the heart and arteries
in middle and advanced life is the rational as well as hopeful
line of treatment which it enables us to pursue. On the whole,
we can control morbific influences more easily than we can alter
pathological processes; and (what is of equal or even greater
importance) a knowledge of the causes of disease often enables us to
prevent what we could not possibly cure. For all that, the etiology
of heart disease furnishes us with but one set of many invaluable
indications for treatment. We must have also a clear mental picture
of the pathological anatomy of the conditions we would attempt to
modify--for instance, of the damage wrought by gout on the mitral
valves and aortic arch, by syphilis on the coronary arteries, by
strain on the walls of the different cardiac chambers. No less
necessary is it for the practitioner to take into account, before
proceeding to prescribe, the clinical characters and course of
the case in hand. As I have said more than once already, a large
proportion of the distress, disabilities and dangers attending
degeneration of the heart are due to some additional or extrinsic
disturbance--distension of the stomach, constipation, worry or
exertion--which alone, not the pathological condition, calls for
therapeutical attention.

It appears, then, that the whole natural history of the diseases
and disorders of the heart--and, I might add, of every individual
case--has to be studied, and the value of its different parts
absolutely and relatively estimated, before rational treatment can
be ordered. How different will treatment be, if ordered on these
principles, from the routine procedure of prescribing a little
strychnine and digitalis for a man with oppression on exertion and a
systolic bruit at the base of his heart!

Let us begin this part of our subject with a brief consideration of
preventive treatment, founded on a knowledge of the cause at work.

Now, the first thing to strike us about these unfavourable
influences is the number of them that could be avoided or controlled
successfully by simple exercise of the will. The toxic effects of
tobacco, alcohol, tea, &c. are due to abuse, from thoughtlessness or
ignorance, or from indisposition rather than inability to exercise
self-control. The abuse of tobacco appears to create so much
discomfort or even alarm, of a kind which the sufferer cannot fail
to refer to its cause, that the remedy is effected automatically,
and no great harm is done. We seldom have to do more than confirm
the patient's suspicions in this direction, and recommend temporary
abstinence from the cigarette or pipe and greater care in the
future. With alcohol it is a different matter. Alcoholism grows by
what it feeds on, and our best efforts are often vain. The present
is hardly an occasion for dwelling on this subject--the duty of the
profession to their patients and friends in respect of the abuse of
alcohol. Still, I should not feel that I had discharged to the best
of my ability, or in full conformity with my strong convictions,
the duties of the honourable position which by your favour I
occupy as Lettsomian Lecturer, if I did not urge you to exercise
more fully than is at present exercised your personal influence to
discourage habitual drinking. I believe (because I have found) that
many men who are not open to arguments of an abstract kind, can
be made to pause and reconsider their manner of living by having
a concrete presentment of their condition and its results placed
before them--in plain English, by being thoroughly frightened.
"Heart disease" is a powerful argument to employ with persons of
this class, and it is one that is also justified by the issues at
stake. Of syphilis and the havoc that it works on heart, aorta and
the vascular system generally, but particularly within the nervous
system, I need not speak. The profession, as I have said, is not
yet sufficiently alive to it: what can the public be expected to
do in the way of prevention? Gout, corpulence and allied metabolic
disorders, those fruitful sources of cardio-vascular disorders and
atheroma, call for temperance not only in drinking but in eating.
Whilst the question continues to be discussed which particular
articles of food ought to be avoided by gouty individuals, let us
all join in offering them one bit of advice of the value of which
there can be no doubt: whatever they eat, to eat little. Moderation
in amount is, speaking broadly, far more important than avoidance of
the theoretical antecedents of uric acid, whether meat, or milk,
or sugar. Let me quote what Dr. George Balfour, who has written so
much and so well on disease of the heart and its treatment, says on
this subject:--"I know of no society that inculcates, by precept or
example, temperance in regard to food; yet there is nothing ages a
man or a woman so rapidly, there is nothing that shortens life so
certainly, and there is nothing that embitters the latter days of
life so much as over-indulgence in food. To those who can afford
thus to transgress--to the well-to-do--excess in food is a much
more serious menace to health and life than excess in drink, and
it is specially so in respect of senile affections of the heart,
some of which have been distinctly recognised to owe their origin
to over-indulgence, while all are distinctly aggravated by it."[15]
With the observance of this simple and wholesome dietetic rule must
go attention to free elimination by all the excretory channels, and
the insurance of sufficient exercise and enjoyment of fresh air.
If we wish to impress this consideration on our own minds and give
effect to it in our practice, let us call to mind for a moment the
number of cases that I have submitted to you of atheroma of the
aorta in stout matronly women of sedentary and luxurious habits, in
whom, indeed, this degeneration is quite as common as in men.

  [15] G. W. Balfour, 'The Senile Heart,' p. 236, 1894.

I have already said so much on the subject of cardiac strain that
it is unnecessary and would be uninteresting to return to the
question of the prevention of it. We have seen how often it occurs
in the middle-aged or old subject by ill-considered attempts at
athleticism. Moderation and due respect for age are the true
guides to the useful enjoyment of exercise after 40. As for the
evil effects of nervous influences on the circulation, in addition
to anxiety, care, misfortune and grief, which are usually beyond
our control, nervous strain, as distinguished from simple hard
intellectual work, often must be relaxed if cardio-vascular damage
is to be prevented. I refer to the cases of persons in positions of
great responsibility with heavy complex prolonged duties, which they
fail to overtake without exhaustion consequent on high pressure and
excitement.

       *       *       *       *       *

I would not have dwelt so long upon the measures calculated to
prevent degeneration of the heart, were it not that they have to be
employed with equal strictness and perseverance in the treatment
of cardio-vascular disease when it is already established and our
assistance is sought with anxiety. The etiological indications have
still to be respected faithfully; on this I need not dwell. The
next question is:--What can be done for the pathological changes
wrought on the arteries and the valves and walls of the heart? In
syphilitic lesions we do not hesitate to say that potassium iodide
should be given freely: it is a specific remedy of great value.
Can the atheromatous process be influenced with equal or with any
success? It depends on toxæmia and anæmia; the obvious indication is
to purify and enrich the blood. This, at least in respect of gout,
glycosuria and corpulence, as we have just seen, must be effected by
a thorough reform in every department of personal hygiene. Arsenic
and moderate doses of iodides, combined with an excess of alkalis,
are calculated to promote the same end. Dr. Mott has shown that
atheroma, whether of valves or of vessels, can be traced in many
instances to disease of the _vasa cordis_ and _vasa vasorum_. This
carries us a step forward in our quest for indications, but the
practical conclusion remains--that the healthy nutrition of the
smaller arteries has to be restored by attention to the blood and
the use of specific remedies.

So much for valvular and vascular lesions. There remains to be
discussed the fulfilment of the greater indication for treatment:
the one which directs and governs the employment of the most
important and successful of all the measures comprised in cardiac
therapeutics. This is the establishment and maintenance of
compensation. The nutrition and activity of the myocardium can be
increased and sustained by means of specific cardiac stimulants
and tonics, such as strychnine, ammonia and the digitalis group of
drugs; by hæmatinics, stomachics and laxatives to afford an abundant
supply of healthy blood; by insuring wholesome nervous influences,
one of the conditions of hypertrophy; and by the employment of the
non-medicinal measures now so extensively used to increase the
vigour and benefit the metabolism of the cardiac walls, particularly
active and passive exercises and baths. This is a comprehensive
statement of the lines of treatment calculated to benefit more or
less all the kinds of cardiac degeneration which I have had occasion
to notice. Of the individual pathological changes, and the rational
treatment indicated for each from this point of view, I will refer
to three only which will serve to illustrate the considerations
which ought to guide us in practice.

In the subject of regular or irregular gout attention to the cause,
that is, to disordered metabolism of the body as a whole and of
the cardiac and arterial walls in particular, promotes, as we have
seen, the recognised conditions of compensation: the etiological
and pathological indications are here practically identical. In
respect of exercise in detail, gentle walking on the level should
be ordered to begin with, that is, exercise short of producing pain
or oppression. The patient had better give up his regular work for
a time, and take advantage as fully as possible of the leisure to
enjoy the benefits of a healthy life in the fresh open air. Very
shortly he will be able to ride, play golf, shoot and cycle slowly.
A course of treatment at one of the best of our native spas or of
the Continental watering-places sometimes makes a new man of the
sufferer from gouty heart. The Nauheim treatment, whether taken
there or in England, may also do real good. But it must not be
employed indiscriminately, as is so often done. The profession
ought to remember (what the public cannot and probably never will
come to understand) that pathological diagnosis must precede
rational treatment, which consists in applying a proper remedy
to the individual case before us, not in fitting every case to a
specialised system or panacea--the essence of quackery.

In planning the treatment of the dilated heart of the
middle-aged man who strained his circulation in youth and comes
to us complaining of a recurrence of præcordial distress and
breathlessness, we have to remember that there is left in the
cardiac walls but a portion of that reserve of elasticity and that
reserve of muscular energy which they normally possess and require
to enable them to meet the stress of exertion. Let me remind you for
a moment that, of the provisions which the heart possesses against
such an emergency or other sudden or severe demand upon its capacity
and activity, one is extensibility of its tissues, by virtue of
which it accommodates within it the considerable increase in the
charge of blood that is poured into it from the active muscles, and
the residues that accumulate within it from insufficient discharge
in the face of increased peripheral resistance. The walls yield
before the increased internal pressure acting on them both _a
tergo_ and _a fronte_; the heart is over-distended, with a passing
sense of discomfort, dyspnœa and lividity; and when the muscular
effort is ended the elasticity corresponding with extensibility of
the walls presently insures the return of the chambers to their
original dimensions. At the same time a second provision comes into
operation. Increased muscular activity is developed in accurate
proportion to the rise of internal pressure and secures sufficient
output from the heart. This, I repeat, is what occurs in the sound
heart. Now, in old parietal strain extensibility and the reserve of
capacity of the chambers which it insures are seriously exhausted;
whilst the muscular function is only maintained by means of
hypertrophy, to which there is necessarily a limit. In these cases
of strain it is impossible to reduce the original dilatation--that
is permanent. But we may and ought to be able to reduce the further
dilatation, if any, that has been produced in connection with recent
failure of nutrition and fresh embarrassment. Therefore, whilst we
promote the nutrition of the elastic and muscular structures of the
myocardium on the general principles which I have just laid down,
we must be distinctly sparing of our demands on them. Everything
approaching effort must be forbidden at once and for a sufficient
time to rest and reinvigorate the cardiac tissues; whilst the
nitrites or small doses of opium will also give relief and restore
confidence in attacks of palpitation and anxiety. "Exercise, but
not exertion," will be the broad rule to follow, at any rate until
it has been proved that greater effort can be made with safety and
actual advantage. But if præcordial embarrassment be the result
of the attempt, or of ordinary professional work, as occasionally
happens, further rest will have to be taken, that is, rest for hours
or days, according to the severity of the symptoms. I have already
mentioned to you that middle-aged patients with cardiac strain,
dating from their youth, occasionally break down in their work for
months or even years. In such an event a thorough change of air
and scene should be combined with rest as a method of treatment. A
long voyage may prove invaluable, or foreign travel of an easy and
interesting kind. These not only rest the heart, but they divert the
mind and remove the curious nervousness or loss of courage which, as
I have said, is developed occasionally in these subjects, previously
so vigorous and confident.

Compare with this line of treatment that which is indicated in acute
cardiac strain after 40. The problem here is not how to deal with
a chronically dilated and hypertrophied heart, but with a heart
which has just yielded during effort, mainly in consequence of
the nutritional impairment of its walls. It is not simply strain
of a heart that had begun to be somewhat precariously nourished
as a natural result of age; the probability is that the heart
was actually gouty in the comprehensive sense of the term, that
is, irritated by uric acid and embarrassed by flatulence, both
mechanically and reflexly; and, indeed, possibly it was damaged
by the atheromatous process. Rest is essential at first in the
treatment of this type of case also; indeed, it is automatically
secured by the distress which accompanies attempts at movement.
But rest must not be carried too far, that is, it must not be
of greater degree or duration than is absolutely necessary as
indicated by the symptoms and signs, lest it aggravate the state
of parietal mal-nutrition and promote fresh gout. At the same time
the diet must be controlled strictly or even severely on the lines
that I laid down for gout, lest the over-feeding which accompanies
rest as a matter of thoughtless routine should have the same
unfortunate effects. A course of treatment at some of the good home
or Continental spas, with special precautions, is distinctly useful
in senile strain, and the Nauheim methods have benefited more than
one case of the kind in my experience, the degree of dilatation
diminishing whilst the vigour of the heart increased. At the same
time cardiac tonics of a medicinal kind are administered judiciously.

I am on the point of passing from the subject of the nutrition of
the myocardium, when it occurs to me that some of you might very
naturally ask me: What about fatty degeneration and the treatment
of it? This is a question peculiarly interesting to me. I have not
dwelt on fatty degeneration of the heart in these lectures, and yet
I have mentioned it again and again. I have said that it is a result
of alcoholism, of gouty atheroma of the coronaries, of syphilitic
arteritis in the same area, of Bright's disease, of profound anæmia
and of phosphorus poisoning; and that I believe it may result from
severe nervous strain of a harassing and depressing character; and
that in connection with each of these causes it has to be regarded
and treated differently. Nothing could well bring home more fully to
us the importance, indeed the necessity, of pursuing in practice the
line of inquiry, prognosis and treatment which I have advocated in
these lectures--the etiological one. Let me ask you also to listen
to a confession of one of the highest authorities on heart disease
in this country. "It is absolutely impossible," says Dr. George
Balfour, "to diagnosticate fatty degeneration of the heart; we may
surmise its existence, but we can only be certain of its presence
when we see it _post mortem_"; and he quotes Fraentzel of Berlin in
support of his statement.[16] It must have occurred to many of you,
as it has occurred to me, how seldom we diagnose fatty degeneration
of the heart until after sudden death. How can we be expected to do
so if we trust only to signs and symptoms, and overlook that which
is the key to the diagnosis--the discovery of the cause that is at
work?

  [16] Balfour, _op. cit._, p. 249.

I have now sketched very broadly the rational treatment of these
disorders and diseases as far as the object of it is to prevent the
occurrence or the extension of them, and to promote compensation of
the disabilities which they produce. It remains for me to notice,
also very briefly, the management of cardio-vascular degenerations
when the heart fails, or when it appears to fail, and distress and
danger demand more direct and immediate attention. I have said
"when the heart appears to fail" of set purpose. I am anxious to
direct your attention, if it be but for a moment, to the fact that
in many instances where præcordial oppression, pain, palpitation
and faintness, with frequent small irregular pulse, are significant
of serious disturbance of the action of the heart, there is no
failure of the myocardium in the proper sense of the term, but only
embarrassment of a temporary character. Do not conclude from this
that I regard the disturbance of the heart as of little account. I
have called it serious, for indeed the patient may perish of it.
What I wish to maintain is that in cardiac degeneration of any
kind, in chronic cardiac dilatation, and in the enlarged heart of
Bright's disease and of emphysema, just as in ordinary valvular
disease, attacks of distress, alarming both to patient and doctor,
often occur which call for nothing more in the way of treatment than
attention to some intercurrent influence--an indigestible meal,
loaded bowels, a nervous shock, a thoughtless effort, a passing
hardship or nervous strain. Digitalis and its allies, strychnine,
alcohol, nitrites, iodides and the rest are out of place in such
an event. Complete rest in bed, a carminative draught, calomel and
saline purgatives, spare and highly digestible diet, reassurance and
a little time are quite sufficient means of treatment.

When true failure occurs, manifested by the familiar phenomena of
residual dilatation of the heart, mechanical congestion and dropsy,
a different set of measures are demanded. Now is the time to attend
with expedition, energy and completeness to the fulfilment of the
three great therapeutical indications for the treatment of cardiac
failure: to reduce the peripheral resistance; to increase the vigour
of ventricular contraction and rehabilitate hypertrophy; and to
remove arrears of work in the form of residual blood in the cardiac
chambers, mechanical congestion of the veins and viscera, and dropsy
of the integuments and serous sacs. Bodily rest; a light, solid
diet, and a definite allowance of alcohol, if required; active
purgation with mercurials, salines and jalap; and the exhibition of
sufficiently large doses of digitalis or one of its congeners, in
combination with saline and other diuretics--these are the means
calculated to attain the desired objects. You will not expect
me to enter into the many details of the management of cardiac
failure. It is not different in any important respect in the man
of middle or advanced age with cardiac degeneration from what it
is in an ordinary case of chronic valvular disease. Only on a few
points do I desire to dwell. First, that we must not be afraid to
purge these patients, if necessary, every morning. Secondly, that
when the appetite flags and flatulence occurs, instead of slops a
blue pill or a dose of calomel should be given, and light solids
persevered with. Third, that digitalis must be given freely, the
dose of the tincture, for instance, being raised to 15 or even 20
minims every four hours, if smaller doses, such as 7½ or 10
minims, fail. Unquestionably there is a disposition on the part of
some practitioners to pause or retrace their steps in the dosage of
this invaluable drug, alarmed by the irregularity, frequency and
smallness of the pulse. All these characters of the pulse call for
more digitalis, not for less. In this connection let me also say
that the most ready and accurate, because measurable, evidence of
the action of digitalis in cardiac failure is strangely disregarded
in ordinary practice--I mean the volume of the renal secretion.
We may be in difficulty, and we may differ with each other, as to
the tension of the patient's pulse and the use of continuing or
modifying the digitalis treatment, when all that we have to do is
to ascertain the exact degree of diuresis. Fourth, that nocturnal
restlessness and sleeplessness are to be met unhesitatingly with
permission to spend the night in an easy chair by the bedside.
Fifth, that, according to my experience, acupuncture and drainage
succeed perfectly in these senile cases with dropsy, as much as 10
pints or more of serum escaping in the course of 24 hours, to the
complete and often lasting relief of the circulation.

And now I must bring these lectures to a close. In doing so I feel
that I have not only to thank you, Sir, and the Fellows of the
Medical Society and our visitors for the favour with which I have
been received and the patience with which you have listened to
me, but at the same time to apologise for the many defects, both
in matter and in form, of what I have presented to you. It is a
fortunate circumstance for me that, whilst the subject was so large
and so difficult, the mode of treatment of it commonly associated
with the Lettsomian Lectures and your kind forbearance have enabled
me to conceal my shortcomings by free selection of less severely
scientific topics, and the employment of an easy style. At the same
time, may I claim a little of your favourable consideration for
the aspect in which I have regarded the disorders and diseases of
the heart and arteries in middle and advanced life? I should be
satisfied with the results of my efforts on this occasion, whatever
may be thought of their form, if I have succeeded in convincing you
of the practical advantage of regarding these complaints from the
side of their causes as well as of their pathological anatomy.

HARRISON AND SONS, Printers in Ordinary to His Majesty, St. Martin's
Lane.




INDEX.

  Acute disease and cardio-vascular degeneration; 39

  Alcohol and cardiac disease; 9, 18

  Alcoholism, Heart in, Course of; 20

  Alcoholism, Heart in, Pathology of; 3, 19, 20

  Alcoholism, Heart in, Prognosis of; 36

  Alcoholism, Heart in, Symptoms and signs of; 13

  Alcoholism, Heart in, Treatment of; 42

  Angina pectoris; 17, 21, 24

  Angina pectoris, false; 35

  Angina pectoris, Prognosis of; 40

  Angina pectoris, Significance of; 35

  Arteries, The, at 20 to 45; 3

  Arteries, The, at 45 to 65; 3, 4

  Arteries, The, at 65 to 75; 4

  Arteries, Degeneration of, and Gout; 7

  Arteries, Diseases of, after 40, causes of; 6

  Arteries, Soundness of, after 40; 5

  Atheroma and Gout; 7

  Atheroma, Treatment of; 44


  Beneke, Professor, on the normal Arteries after 40; 3

  Beneke, Professor, on the normal Heart after 40; 3

  Bright's disease and cardio-vascular disease; 11, 29

  Bruit de galop; 35


  Causes of cardio-vascular disease; 9

  Coffee and cardiac disorders; 9

  Compensation, Maintenance of; 44

  Cycling and cardiac strain; 6


  Diabetes and cardio-vascular disease; 10

  Diagnosis, Differential, of cardio-vascular disease; 3


  Emphysema and cardio-vascular disease; 11

  Exercise, Abuse of, and cardio-vascular disease; 8, 26

  Exercise, after 40, Uses of; 45


  Failure of Heart, Treatment of; 48

  Failure of Heart, with Digitalis; 49

  Failure of Heart, with Drainage; 49

  Failure of Heart, with Purgatives; 49

  Faintness, significance of; 35

  Fatty degeneration, Diagnosis of; 47

  Fatty degeneration, Treatment of; 47

  Fevers, Acute specific, and cardio-vascular disease; 11


  Glycosuria and Heart Disease; 22

  Glycosuria and Heart Disease, Prognosis of; 36

  Glycosuria and Heart Disease, Symptoms and Signs of; 22

  Golf and cardiac strain; 7

  Gout and Atheroma; 7

  Gout and cardiac strain; 7

  Gout as a cause of cardio-vascular disease; 9

  Gout and Heart Disease; 20

  Gout and Heart Disease, Prognosis of; 36

  Gout and Heart Disease, Symptoms and signs of; 20

  Gout and Heart Disease, Treatment of; 42, 45

  Gout, Irregular; 10

  Gouty Heart; 20


  Heart, The, at 20 to 45; 3

  Heart, at 45 to 65; 4

  Heart, at 65 to 75; 4

  Heart of the business man; 12

  Heart, Disorder of, after 40, Causes of; 6

  Heart, Failure of, Treatment of; 48

  Heart, Family; 14

  Heart, normal, The, after 40; 3

  Heart, Soldier's, The; 12

  Heart, Strain of; 6

  Heart, Strain of, after 40; 6

  Heart, Strain of, in Gout; 7

  High arterial tension from nervous strain; 8


  Influenza and cardio-vascular disease; 11


  Lead and cardiac disorder; 9


  Metabolism, Disturbances of, and cardio-vascular disease; 9

  Murmur, Aortic Diastolic, Significance of; 33

  Murmur, Systolic Diastolic; 33

  Murmur, Endocardial Diastolic; 33

  Murmur, Mitral, Presystolic Diastolic; 33

  Murmur, Mitral, Systolic; 33


  Nauheim treatment; 45

  Nervous influences a cause of cardio-vascular disease; 8

  Nervous Strain and Heart Disease; 29

  Nervous Strain and Heart Disease, Prevention of; 43

  Nervous Strain and Heart Disease, Prognosis of; 39

  Nervous Strain and Heart Disease, Symptoms and signs of; 29


  Obesity and cardio-vascular disease; 10, 22

  Obesity and Heart Disease, Symptoms and signs; 22

  Old Age, Normal arteries in; 5

  Old Age, heart in; 5

  Operations in cardio-vascular degeneration; 39


  Palpitation, Significance of; 35

  Physical stress, a cause of cardio-vascular disease; 6

  Prognosis, Elements of; 36, 40

  Pseudo-angina pectoris; 35


  Rowing and cardiac strain; 7

  Running and cardiac strain; 7


  Sound, First, reduplicated; 34

  Sound, Second, accentuated; 34

  Strain of Heart after 40, Prevention of; 45

  Strain of Heart after 40, Prognosis of; 38

  Strain of Heart after 40, Symptoms and signs of; 23

  Strain of Heart after 40, Treatment of; 46

  Strain of Heart before 40, Prognosis of; 38

  Strain of Heart before 40, Symptoms and signs of; 25

  Strain of Heart before 40, Treatment of; 45

  Syphilis, a cause of cardio-vascular disease; 10

  Syphilitic Heart Disease, Prognosis of; 37

  Syphilitic Heart Disease, Symptoms and signs of; 28

  Syphilitic Heart Disease, Treatment of; 44


  Tea and cardiac disorder; 9

  Tension, High, Significance of; 35

  Tobacco Heart; 9, 15

  Tobacco Heart, Prognosis of; 36

  Tobacco Heart, Symptoms and signs of; 15

  Tobacco Heart, Treatment of; 42

  Treatment of cardiac disease, Preventive; 42

  Treatment of cardiac disease, Principles of; 41





End of the Project Gutenberg EBook of The Lettsomian Lectures 1900-1901, by 
J. Mitchell Bruce

*** END OF THIS PROJECT GUTENBERG EBOOK THE LETTSOMIAN LECTURES 1900-1901 ***

***** This file should be named 43780-0.txt or 43780-0.zip *****
This and all associated files of various formats will be found in:
        http://www.gutenberg.org/4/3/7/8/43780/

Produced by Ian Deane, Julia Neufeld and the Online
Distributed Proofreading Team at http://www.pgdp.net


Updated editions will replace the previous one--the old editions
will be renamed.

Creating the works from public domain print editions means that no
one owns a United States copyright in these works, so the Foundation
(and you!) can copy and distribute it in the United States without
permission and without paying copyright royalties.  Special rules,
set forth in the General Terms of Use part of this license, apply to
copying and distributing Project Gutenberg-tm electronic works to
protect the PROJECT GUTENBERG-tm concept and trademark.  Project
Gutenberg is a registered trademark, and may not be used if you
charge for the eBooks, unless you receive specific permission.  If you
do not charge anything for copies of this eBook, complying with the
rules is very easy.  You may use this eBook for nearly any purpose
such as creation of derivative works, reports, performances and
research.  They may be modified and printed and given away--you may do
practically ANYTHING with public domain eBooks.  Redistribution is
subject to the trademark license, especially commercial
redistribution.



*** START: FULL LICENSE ***

THE FULL PROJECT GUTENBERG LICENSE
PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK

To protect the Project Gutenberg-tm mission of promoting the free
distribution of electronic works, by using or distributing this work
(or any other work associated in any way with the phrase "Project
Gutenberg"), you agree to comply with all the terms of the Full Project
Gutenberg-tm License available with this file or online at
  www.gutenberg.org/license.


Section 1.  General Terms of Use and Redistributing Project Gutenberg-tm
electronic works

1.A.  By reading or using any part of this Project Gutenberg-tm
electronic work, you indicate that you have read, understand, agree to
and accept all the terms of this license and intellectual property
(trademark/copyright) agreement.  If you do not agree to abide by all
the terms of this agreement, you must cease using and return or destroy
all copies of Project Gutenberg-tm electronic works in your possession.
If you paid a fee for obtaining a copy of or access to a Project
Gutenberg-tm electronic work and you do not agree to be bound by the
terms of this agreement, you may obtain a refund from the person or
entity to whom you paid the fee as set forth in paragraph 1.E.8.

1.B.  "Project Gutenberg" is a registered trademark.  It may only be
used on or associated in any way with an electronic work by people who
agree to be bound by the terms of this agreement.  There are a few
things that you can do with most Project Gutenberg-tm electronic works
even without complying with the full terms of this agreement.  See
paragraph 1.C below.  There are a lot of things you can do with Project
Gutenberg-tm electronic works if you follow the terms of this agreement
and help preserve free future access to Project Gutenberg-tm electronic
works.  See paragraph 1.E below.

1.C.  The Project Gutenberg Literary Archive Foundation ("the Foundation"
or PGLAF), owns a compilation copyright in the collection of Project
Gutenberg-tm electronic works.  Nearly all the individual works in the
collection are in the public domain in the United States.  If an
individual work is in the public domain in the United States and you are
located in the United States, we do not claim a right to prevent you from
copying, distributing, performing, displaying or creating derivative
works based on the work as long as all references to Project Gutenberg
are removed.  Of course, we hope that you will support the Project
Gutenberg-tm mission of promoting free access to electronic works by
freely sharing Project Gutenberg-tm works in compliance with the terms of
this agreement for keeping the Project Gutenberg-tm name associated with
the work.  You can easily comply with the terms of this agreement by
keeping this work in the same format with its attached full Project
Gutenberg-tm License when you share it without charge with others.

1.D.  The copyright laws of the place where you are located also govern
what you can do with this work.  Copyright laws in most countries are in
a constant state of change.  If you are outside the United States, check
the laws of your country in addition to the terms of this agreement
before downloading, copying, displaying, performing, distributing or
creating derivative works based on this work or any other Project
Gutenberg-tm work.  The Foundation makes no representations concerning
the copyright status of any work in any country outside the United
States.

1.E.  Unless you have removed all references to Project Gutenberg:

1.E.1.  The following sentence, with active links to, or other immediate
access to, the full Project Gutenberg-tm License must appear prominently
whenever any copy of a Project Gutenberg-tm work (any work on which the
phrase "Project Gutenberg" appears, or with which the phrase "Project
Gutenberg" is associated) is accessed, displayed, performed, viewed,
copied or distributed:

This eBook is for the use of anyone anywhere at no cost and with
almost no restrictions whatsoever.  You may copy it, give it away or
re-use it under the terms of the Project Gutenberg License included
with this eBook or online at www.gutenberg.org

1.E.2.  If an individual Project Gutenberg-tm electronic work is derived
from the public domain (does not contain a notice indicating that it is
posted with permission of the copyright holder), the work can be copied
and distributed to anyone in the United States without paying any fees
or charges.  If you are redistributing or providing access to a work
with the phrase "Project Gutenberg" associated with or appearing on the
work, you must comply either with the requirements of paragraphs 1.E.1
through 1.E.7 or obtain permission for the use of the work and the
Project Gutenberg-tm trademark as set forth in paragraphs 1.E.8 or
1.E.9.

1.E.3.  If an individual Project Gutenberg-tm electronic work is posted
with the permission of the copyright holder, your use and distribution
must comply with both paragraphs 1.E.1 through 1.E.7 and any additional
terms imposed by the copyright holder.  Additional terms will be linked
to the Project Gutenberg-tm License for all works posted with the
permission of the copyright holder found at the beginning of this work.

1.E.4.  Do not unlink or detach or remove the full Project Gutenberg-tm
License terms from this work, or any files containing a part of this
work or any other work associated with Project Gutenberg-tm.

1.E.5.  Do not copy, display, perform, distribute or redistribute this
electronic work, or any part of this electronic work, without
prominently displaying the sentence set forth in paragraph 1.E.1 with
active links or immediate access to the full terms of the Project
Gutenberg-tm License.

1.E.6.  You may convert to and distribute this work in any binary,
compressed, marked up, nonproprietary or proprietary form, including any
word processing or hypertext form.  However, if you provide access to or
distribute copies of a Project Gutenberg-tm work in a format other than
"Plain Vanilla ASCII" or other format used in the official version
posted on the official Project Gutenberg-tm web site (www.gutenberg.org),
you must, at no additional cost, fee or expense to the user, provide a
copy, a means of exporting a copy, or a means of obtaining a copy upon
request, of the work in its original "Plain Vanilla ASCII" or other
form.  Any alternate format must include the full Project Gutenberg-tm
License as specified in paragraph 1.E.1.

1.E.7.  Do not charge a fee for access to, viewing, displaying,
performing, copying or distributing any Project Gutenberg-tm works
unless you comply with paragraph 1.E.8 or 1.E.9.

1.E.8.  You may charge a reasonable fee for copies of or providing
access to or distributing Project Gutenberg-tm electronic works provided
that

- You pay a royalty fee of 20% of the gross profits you derive from
     the use of Project Gutenberg-tm works calculated using the method
     you already use to calculate your applicable taxes.  The fee is
     owed to the owner of the Project Gutenberg-tm trademark, but he
     has agreed to donate royalties under this paragraph to the
     Project Gutenberg Literary Archive Foundation.  Royalty payments
     must be paid within 60 days following each date on which you
     prepare (or are legally required to prepare) your periodic tax
     returns.  Royalty payments should be clearly marked as such and
     sent to the Project Gutenberg Literary Archive Foundation at the
     address specified in Section 4, "Information about donations to
     the Project Gutenberg Literary Archive Foundation."

- You provide a full refund of any money paid by a user who notifies
     you in writing (or by e-mail) within 30 days of receipt that s/he
     does not agree to the terms of the full Project Gutenberg-tm
     License.  You must require such a user to return or
     destroy all copies of the works possessed in a physical medium
     and discontinue all use of and all access to other copies of
     Project Gutenberg-tm works.

- You provide, in accordance with paragraph 1.F.3, a full refund of any
     money paid for a work or a replacement copy, if a defect in the
     electronic work is discovered and reported to you within 90 days
     of receipt of the work.

- You comply with all other terms of this agreement for free
     distribution of Project Gutenberg-tm works.

1.E.9.  If you wish to charge a fee or distribute a Project Gutenberg-tm
electronic work or group of works on different terms than are set
forth in this agreement, you must obtain permission in writing from
both the Project Gutenberg Literary Archive Foundation and Michael
Hart, the owner of the Project Gutenberg-tm trademark.  Contact the
Foundation as set forth in Section 3 below.

1.F.

1.F.1.  Project Gutenberg volunteers and employees expend considerable
effort to identify, do copyright research on, transcribe and proofread
public domain works in creating the Project Gutenberg-tm
collection.  Despite these efforts, Project Gutenberg-tm electronic
works, and the medium on which they may be stored, may contain
"Defects," such as, but not limited to, incomplete, inaccurate or
corrupt data, transcription errors, a copyright or other intellectual
property infringement, a defective or damaged disk or other medium, a
computer virus, or computer codes that damage or cannot be read by
your equipment.

1.F.2.  LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except for the "Right
of Replacement or Refund" described in paragraph 1.F.3, the Project
Gutenberg Literary Archive Foundation, the owner of the Project
Gutenberg-tm trademark, and any other party distributing a Project
Gutenberg-tm electronic work under this agreement, disclaim all
liability to you for damages, costs and expenses, including legal
fees.  YOU AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT
LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE
PROVIDED IN PARAGRAPH 1.F.3.  YOU AGREE THAT THE FOUNDATION, THE
TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE
LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE OR
INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH
DAMAGE.

1.F.3.  LIMITED RIGHT OF REPLACEMENT OR REFUND - If you discover a
defect in this electronic work within 90 days of receiving it, you can
receive a refund of the money (if any) you paid for it by sending a
written explanation to the person you received the work from.  If you
received the work on a physical medium, you must return the medium with
your written explanation.  The person or entity that provided you with
the defective work may elect to provide a replacement copy in lieu of a
refund.  If you received the work electronically, the person or entity
providing it to you may choose to give you a second opportunity to
receive the work electronically in lieu of a refund.  If the second copy
is also defective, you may demand a refund in writing without further
opportunities to fix the problem.

1.F.4.  Except for the limited right of replacement or refund set forth
in paragraph 1.F.3, this work is provided to you 'AS-IS', WITH NO OTHER
WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO
WARRANTIES OF MERCHANTABILITY OR FITNESS FOR ANY PURPOSE.

1.F.5.  Some states do not allow disclaimers of certain implied
warranties or the exclusion or limitation of certain types of damages.
If any disclaimer or limitation set forth in this agreement violates the
law of the state applicable to this agreement, the agreement shall be
interpreted to make the maximum disclaimer or limitation permitted by
the applicable state law.  The invalidity or unenforceability of any
provision of this agreement shall not void the remaining provisions.

1.F.6.  INDEMNITY - You agree to indemnify and hold the Foundation, the
trademark owner, any agent or employee of the Foundation, anyone
providing copies of Project Gutenberg-tm electronic works in accordance
with this agreement, and any volunteers associated with the production,
promotion and distribution of Project Gutenberg-tm electronic works,
harmless from all liability, costs and expenses, including legal fees,
that arise directly or indirectly from any of the following which you do
or cause to occur: (a) distribution of this or any Project Gutenberg-tm
work, (b) alteration, modification, or additions or deletions to any
Project Gutenberg-tm work, and (c) any Defect you cause.


Section  2.  Information about the Mission of Project Gutenberg-tm

Project Gutenberg-tm is synonymous with the free distribution of
electronic works in formats readable by the widest variety of computers
including obsolete, old, middle-aged and new computers.  It exists
because of the efforts of hundreds of volunteers and donations from
people in all walks of life.

Volunteers and financial support to provide volunteers with the
assistance they need are critical to reaching Project Gutenberg-tm's
goals and ensuring that the Project Gutenberg-tm collection will
remain freely available for generations to come.  In 2001, the Project
Gutenberg Literary Archive Foundation was created to provide a secure
and permanent future for Project Gutenberg-tm and future generations.
To learn more about the Project Gutenberg Literary Archive Foundation
and how your efforts and donations can help, see Sections 3 and 4
and the Foundation information page at www.gutenberg.org


Section 3.  Information about the Project Gutenberg Literary Archive
Foundation

The Project Gutenberg Literary Archive Foundation is a non profit
501(c)(3) educational corporation organized under the laws of the
state of Mississippi and granted tax exempt status by the Internal
Revenue Service.  The Foundation's EIN or federal tax identification
number is 64-6221541.  Contributions to the Project Gutenberg
Literary Archive Foundation are tax deductible to the full extent
permitted by U.S. federal laws and your state's laws.

The Foundation's principal office is located at 4557 Melan Dr. S.
Fairbanks, AK, 99712., but its volunteers and employees are scattered
throughout numerous locations.  Its business office is located at 809
North 1500 West, Salt Lake City, UT 84116, (801) 596-1887.  Email
contact links and up to date contact information can be found at the
Foundation's web site and official page at www.gutenberg.org/contact

For additional contact information:
     Dr. Gregory B. Newby
     Chief Executive and Director
     gbnewby@pglaf.org

Section 4.  Information about Donations to the Project Gutenberg
Literary Archive Foundation

Project Gutenberg-tm depends upon and cannot survive without wide
spread public support and donations to carry out its mission of
increasing the number of public domain and licensed works that can be
freely distributed in machine readable form accessible by the widest
array of equipment including outdated equipment.  Many small donations
($1 to $5,000) are particularly important to maintaining tax exempt
status with the IRS.

The Foundation is committed to complying with the laws regulating
charities and charitable donations in all 50 states of the United
States.  Compliance requirements are not uniform and it takes a
considerable effort, much paperwork and many fees to meet and keep up
with these requirements.  We do not solicit donations in locations
where we have not received written confirmation of compliance.  To
SEND DONATIONS or determine the status of compliance for any
particular state visit www.gutenberg.org/donate

While we cannot and do not solicit contributions from states where we
have not met the solicitation requirements, we know of no prohibition
against accepting unsolicited donations from donors in such states who
approach us with offers to donate.

International donations are gratefully accepted, but we cannot make
any statements concerning tax treatment of donations received from
outside the United States.  U.S. laws alone swamp our small staff.

Please check the Project Gutenberg Web pages for current donation
methods and addresses.  Donations are accepted in a number of other
ways including checks, online payments and credit card donations.
To donate, please visit:  www.gutenberg.org/donate


Section 5.  General Information About Project Gutenberg-tm electronic
works.

Professor Michael S. Hart was the originator of the Project Gutenberg-tm
concept of a library of electronic works that could be freely shared
with anyone.  For forty years, he produced and distributed Project
Gutenberg-tm eBooks with only a loose network of volunteer support.

Project Gutenberg-tm eBooks are often created from several printed
editions, all of which are confirmed as Public Domain in the U.S.
unless a copyright notice is included.  Thus, we do not necessarily
keep eBooks in compliance with any particular paper edition.

Most people start at our Web site which has the main PG search facility:

     www.gutenberg.org

This Web site includes information about Project Gutenberg-tm,
including how to make donations to the Project Gutenberg Literary
Archive Foundation, how to help produce our new eBooks, and how to
subscribe to our email newsletter to hear about new eBooks.