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.
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.
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.