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.